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College  of  l^\)^iidani  anb  ^urgconB 


&ibtn  fap 

©r.  etitoin  ^.  Cragin 

1859-1918 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practiceofmidwifOOgala 


THE     PRACTICE     OF     MIDWIFERY 


THE     PRACTICE 
OF     MIDWIFERY 


BEING   THE   SEVENTH   EDITION    OF   DR.   GALABIN'S 

MANUAL     OF     MIDWIFERY,     GREATLY 

ENLARGED    AND    EXTENDED 


BY 

ALFRED     LEWIS     GALABIN 

M.A.,    M.D.    Cantab.;    F.R.C.P.    Lond. 

LATE   FELLOW    OF    TRINITY    COLLEGE,    CAMBRIDGE  ;    CONSULTING    OBSTETRIC    PHYSICIAN    TO    GUY's 

HOSPITAL  ;      LATE     PRESIDENT    OF    THE     OBSTETRICAL     SOCIETY    OF    LONDON  ;      LATE 

EXAMINER    IN    OBSTETRIC    MEDICINE    TO    THE    UNIVERSITIES    OF    OXFORD, 

CAMBRIDGE,  LONDON,  AND  NEW  ZEALAND,  AND  TO  THE  ROYAL 

COLLEGES    OF    PHYSICIANS    AND     SURGEONS 


GEORGE     BLACKER 

M.D.,  B.S.  Lend.;    F.R.C.S.  Eng.  ;    F.R.C.P.  Lond. 

FELLOW    OF    UNIVERSITY    COLLEGE,    LONDON  ;     OBSTETRIC    PHYSICIAN    TO    UNIVERSITY    COLLEGE 

HOSPITAL,  AND  THE    GREAT    NORTHERN    CENTRAL    HOSPITAL  ;   TEACHER   OF   PRACTICAL 

MIDWIFERY,        UNIVERSITY        COLLEGE        HOSPITAL        MEDICAL        SCHOOL  ; 

EXAMINER   IN    OBSTETRIC    MEDICINE  TO  THE  ROYAL  COLLEGES 

OF    PHYSICIANS    AND    SURGEONS 


ILLUSTRATED    WITH    503    ENGRAVINGS 

Many  0/  the  New  Illustrations  specially  drawn  by  T.   W.  P.  Lazvrcnce,  M.B.,  B.S.,  J^.R.C.S. 

P athologist  to  University  College  Hospital,  and  Curator  of  the  Museum  0/ 

Pathology,  University  College  Hospital  Medical  School 


lie  to  |orh 
THE    MACMILLAN    COMPANY 


BEABBUBY,   AGNEW,   &    CO.    LD.,   PRINTERS, 
LONDON   AND   TONBEIDGE 


Treface 


'TT^HE  present  edition  of  this  work  has  been  thoroughly  revised, 
and  to  a  large  extent  rewritten.  The  -subjects  chiefly 
requiring  revision  have  been  the  development  of  the  ovary  and 
of  the  early  ovum,  the  physiology  of  the  foetus  and  of  the  puer- 
peral state,  the  mechanism  of  labour,  the  lower  uterine  segment, 
the  pathology  of  eclampsia,  hydatidiform  mole,  accidental  com- 
plications of  pregnancy,  narcosis  in  labour,  vaginal  and  extra- 
peritoneal Cesarean  section,  and  pubiotomy. 

A  new  chapter  has  been  added  on  "  Injuries  and  Diseases  of  the 
Foetus." 

One  hundred  and  seventy-four  new  figures  have  been  added, 
and  many  of  the  others  modified  or  redrawn.  Most  of  the  new 
figures  have  been  drawn  specially  for  the  work  by  Mr.  T.  W.  P. 
Lawrence,  F.E.C.S.  Altogether  there  are  nearly  three  hundred 
new  illustrations. 

The  form  of  the  page  has  been  altered,  and  the  additions  have 
rendered  it  necessary  to  enlarge  the  book  by  some  two  hundred 
pages. 

Mnji,    1010. 


Table  of  Contents 


CHAPTEB  I. 

Aj^atomy  of  the  Pelvis. 

PAGE 

The  pelvis  as  a  whole. — Differences  between  male  and  female  j)elves. — 
Inclination  of  the  pelvis. — Articulations  of  the  pelvis. — Changes  in 
pelvic  joints  during  pregnancy. — Mechanical  action  of  the  sacrum. — 
Measurements  of  the  pelvis. — Diameters. — Alterations  of  diameters 
by  soft  parts. — Other  measurements. — Axis  of  the  pelvis. — Axes  of 
the  several  planes. — ^The  pelvis  in  infancy  and  childhood. — Develop- 
ment of  the  pelvis.  — Changes  in  the  sacrum. — Changes  in  the  lateral 
pelvic  wall. — Effects  of  the  pressure  of  the  femora. — Effects  of  sitting. 
— Effects  of  muscular  action         ........         1 


CHAPTER  II. 

Ovulation  and  Conception. 

Development  of  the  ovaries  and  ova. — Structure  of  the  ovary. — Relation 
of  menstruation  to  ovulation. — Character  of  the  menstrual  fluid. — 
Source  of  the  menstrual  blood. — Theory  of  menstruation. — Cycle  of 
menstrual  changes. — Maturation  of  the  Graafian  follicle. — Period  of 
ruj)ture  of  the  Grraafian  follicle. — Eormationof  the  corpus  luteum. — 
Commencement  and  duration  of  menstruation. — Conception. — Period 
of  possible  impregnation       .........       34 


CHAPTER   III. 

Early  Development  of  the  Ovum. 

Maturation  of  the  oocyte. — Fertilisation  and  segmentation  of  the 
ovum. — The  decidua. — Further  changes  in  the  ovum. — The  formation 
of  the  mesoderm. — The  amnion. — Structure  of  the  amnion. — The 
li([uor  amnii. — The  allantcns. — Formation  of  bloodvessels    ...       65 


viii  Table  of  Contents. 

CHAPTEE   IV. 

The  Choeion,  Placenta,  and  Umbilical  Coed. 

PAGE 

The  chorion. — The  placenta. — Varieties  of  placenta  in  animals. — Formation 
of  human  placenta. — Characters  of  full-grown  placenta. — Functions  of 
the  placenta. — The  umbilical  cord        .         .         .         .         .         .  ^       .       92 


CHAPTEE  V. 

Development  of  the  Fcetus. 

The  fcetus  in  successive  months. — The  foetus  at  full  term. — Circulation  of 
the  foetus. — Changes  in  the  foetal  circulation  at  birth. — Physiology  of 
tbe  foetus 115 


CHAPTEE  VI. 

The  Anatomy  of  the  Fcetal  Head. 

The  head  as  a  wbole. — Sutures  and  fontanelles. — Diameters. — Influence  of 
sex  and  race  on  the  dimensions  of  the  foetal  head. — Ai-ticulation  of  the 
foetal  head 127 


CHAPTEE   VII. 

The  Attitude,  Presentation,  Lie,  and  Position  of  the  Fcetus 

IN  TJtero. 

Attitude. — Presentation  and  lie. — Causation  of  head  presentation       .         .     136 


CHAPTEE  VIII. 

Changes  in  the  Maternal  Organism  consequent  upon  Pregnancy. 

Changes  in  the  uterus. — Uterine  vessels. — Uterine  lymj)hatics  and  nerves. 
— Size  of  the  uterus  in  the  successive  months  of  pregnancy. — Changes 
in  the  cervix  uteri. — The  cervix  and  lower  uterine  segment. — Changes 
in  the  vagina  and  other  adjacent  parts. — Mechanical  effects  on  other 
parts. — Changes  in  the  breasts. — Diagnostic  value  of  mammary 
changes. — Changes  in  the  body  generally. — Circulation. — Blood 
pressure  — Eespiration. — Puerperal  osteoj)hytes. — -Urine. — Nervous 
system. — Pigmentatiou 145 


Table  of  Contents.  ix 

CHAPTEE   IX. 

Diagnosis  of  Pkegnancy. 

PAGE 

Symptomatic  signs. — Suppression  of  menstruation. — Morning  sickness. — 
Mammary  clianges. — Physical  or  direct  signs. — Enlargement  of  the 
uterus  and  of  the  abdomen. — Hegar's  sign.  —  Changes  in  the  cervix 
uteri  and  vagina. — Violet  coloration  of  cervix  and  vagina. — Inter- 
mittent uterine  contractions. — Ballottement. — Foetal  movements. — 
Uterine  souffle. — Foetal  heart-sounds. — Funic  souffle. — Eeca]3itulation 
of  signs  in  order  of  date. — Differential  diagnosis, — Pseudocyesis. — 
Diagnosis  of  life  or  death  of  foetus. — Diagnosis  between  first  and 
subsequent  pregnancies         .........     171 


CHAPTEE  X. 

The  Dxteation  and  Hygiene  of  Pregnancy. 

The  duration  of  pregnancy. — Calculation  of  probable  date  of  delivery. 

— Hygiene  of  pregnancy       .         .         .         .         .         .         .         •         .195 

CHAPTEE   XI. 

Laboue. 

Causes  which  determine  labour. — Nervous  mechanism  of  uterine  contrac- 
tions.— Arrangement  of  nerve-centres  and  afferent  nerves. — Mode  in 
which  the  uterus  contracts. — Eetraction  of  the  uterus. — Polarity  of 
the  uterus. — Cause  of  the  pain  in  labour. — Effect  of  the  pains  on  the 
general  sj'stem. — The  course  of  x^artuiition. — Premonitory  symptoms. 
— Spurious  pains. — The  three  stages  of  labour. — The  first  stage. — 
Mode  in  which  the  cervix  and  vagina  expand. — Caput  succedaneum 
in  the  first  stage. — Second  or  expulsive  stage    .....     203 

CHAPTEE   XII. 

The  Mechanism  of  Laboue. 

General  intra-uterine  pressure. — Direct  uterine  pressure. — Auxiliary 
forces. — Magnitude  of  the  forces. — Eesistances. — Positions  of  the 
head  in  vertex  i)resentations. — Movements  of  the  head  and  of  the 
trunk  of  the  foetus. — Descent.— Flexion. — Internal  rotation. — Exten- 
sion.— Restitution. — External  rotation. — Eolations  of  movements  to 
each  other. — Mechanism  in  occipito-posterior  positions. — Mechanisms 
in  unreduced  occipito-posterior  presentations. — Lateral  obliquity. 
— Moulding  of  foetal  head  in  vertex  positions. — Caput  succedaneum. 
— Diagnosis  of  cranial  positions. — By  abdominal  palpation. — By 
vaginal  examination. — The  third  stage. — Mechanism  of  detachment. — 
Mechanism  of  expulsion. — Separation  and  expulsion  of  membranes. — 
Duration  of  labour 2;j0 


X  Table  of  Contents. 

CHAPTBE  XIII. 

Management  of  Normai.  Labour. 

PAGE 

Eequisites  to  be  taken  by  accoucheur. —  Antiseptic  precautions. — Preliminary 
preparations. —  Position  of  tbe  patient. — Examination. — Management 
of  first  stage. — Artificial  rupture  of  membranes. — Management  of 
second  stage. — Management  of  occipito-posterior  positions. — Preserva- 
tion of  the  perineum. — Expulsion  of  the  trunk. — Ligature  of  the 
funis. — Management  of  the  third  stage. — Expression  of  the  placenta. 
— Examination  of  the  j)lacenta. — Examination  of  perineiim. — Use  of 
the  binder. — Use  of  anesthetics  in  labour. — Scopolamine  morphine 
narcosis. — Maternal  mortality  in  childbirth. — Foetal  mortality  .  .     290 


CHAPTEE   XIV. 

Face  Presentations. 

Frequency. —  Causation. — Varieties. — Mechanism  of  labour. — Extension. 
— Internal  rotation.—  Flexion. — Eestitution.  — External  rotation. — 
Lateral  obliquities.  —  Contrasts  between  mechanism  of  face  and 
vertex  presentation. — Caput  succedaneum. —  Moulding  of  head.  — 
Diagnosis.  —  Prognosis.  —  Brow  presentation. — Treatment  of  face 
presentations. — Management  of  mento-posterior  positions. — Treat- 
ment of  protracted  labour. — Treatment  of  brow  presentation        .         .     321 


CHAPTEE   XV. 

Pelvic  Presentations. 

.Causation. — Varieties. — Diagnosis.— Mechanism  of  labour. — Mechanism 
in  dorso-posterior  jiositions.  —  Irregularities  of  mechanism.  — 
Mechanism  in  foot  or  knee  presentation. — Moulding  of  child. — 
Prognosis. — Management. — Extraction  of  head   .....     345 


CHAPTEE   XVI. 

Multiple  PREGNiUS^CY. 

Causation. — Binovular  twins. — Uniovular  twins. — Acardiac  monsters. — 
Sex  of  the  children. — Course  of  pregnancy. — Diagnosis. — Presenta- 
tion.— Labour-.— Management  of  labour. — Superfoetation     .         .         .     365 


Table  of  Contents.  xi 

CHAPTEE  XVII. 

Physiology  of  the  Puerperal  State. 

PAGE 

Pulse  and  temperatui'e. — Secretions  and  excretions. — Involution  of  uterus. 
— Changes  in  mucous  membrane. — The  placental  site. — The  cervix 
uteri  and  vagina.  —  The  lochia.  —  Condition  of  the  blood.  —  Body 
weight. — After-pains. — Secretion  of  milk. — Composition  of  the  milk. 
— Diagnosis  of  puerperal  state. — Diagnosis  of  parity. — Differences 
between  multiparous  and  parous  uterus. — The  new-born  infant  .         .     380 


CHAPTEE  XVIII. 

Management  of  the  Puerperal  State. 

Cleanliness. — Diet  and  general  management. — Action  of  bowels. — Lacta- 
tion.— Management  of  new-born  infant. — Selection  of  wet-nurse. — 
Artificial  feeding 401 

CHAPTEE   XIX. 

Abnormal  Pregnancy. 

Ectopic  or  extra-uterine  foetation. — Yaiieties. — Causation. — Pathological 
anatomy. — Ovarian  foetation. — Tubal  foetation. — Tubal  mole. — Tubal 
abortion. — Pupture  of  the  tube. — Hsematocele  and  Hsematoma. — 
Tubo-ovarian  foetation. — Tubo-uterine  foetation. — Intra-ligamentous 
foetation.—  Secondary  abdominal  foetation. — Primary  abdominal  foeta- 
tion.— Pregnancy  in  rudimentary  uterine  horn. — Symptoms. — Diag- 
nosis.— Prognosis. — Treatment. — Operation  .....     417 

CHAPTEE   XX. 

DiSORDEKS   OF   PREGNANCY  DUE   TO   EeFLEX   ToXIC   AND   MECHANICAL 

Causes. 

Classification — Nausea  and  vomiting. — Other  digestive  disturbances. — 
•Salivation.  —  Gingivitis.  —  Anasmia. — Neuralgia.  —  Cough,  dyspnoea, 
palpitation,  syncope. — Eruptions. —  Pruritus. — Chorea. — Hysteria. — 
Albuminuria.  — Eclampsia.  —  Causation. —  Pathology. — Diagnosis. — 
Treatment. — CEdema. — Varicose  veins. — Haemorrhoids        .         .         .     455 


CHAPTEE  XXI. 

Abnormalities  of  the  Uterus. 

Congenital  malformations.  —Displacements. — Anteversion  and  anteflexion. 
— Retroversion  and  retroflexion. — Prolapse  of  uterus  and  vagina. — 
Hernia  of  uterus 49;j 


xii  Table  of  Contents. 

CHAPTEE   XXII. 

Diseases  of  Decidua  and  Ovum. 

PAGE 

Decidual  endometritis. — Anomalies  of  decidua  basalis  and  placenta. — 
Anomalies  of  form  and  size.  —  Congestion  and  inflammation  of 
placenta. — Infarcts. — Calcification. — Syphilis. — Tubercle.  —  Tumours 
of  placenta. — CEdema. — Carneous  mole. — Blighted  ovum. — Hydatidi- 
form  mole. — Hydramnios  or  Hydrops  amnii.  —Deficiency  of  liquor 
amnii. — Anomalies  of  funis.— Knots. — Coils. — Torsion. — Anomalies 
and  diseases  of  foetus. — Intra-uterine  amputation  of  limbs. — Con- 
genital dislocations. — Exomphalos. — Intra-uterine  fracture  of  bones. 
— Rachitis. — Intra-uterine  death. — Retention  in  utero,  maceration, 
miimmification. — ]\Iissed  labour 510 


CHAPTEE   XXIII. 

Accidental  Complications  of  Pregnancy. 

Chronic  cardiac  disease. — ^Acute  endocarditis. — Phthisis. — Acute  lobar 
j)neumonia. — Jaundice. — Acute  atrophy  of  liver. — Diabetes. — Pj^elo- 
nephritis. — Brouchocele.  —  Htemorrhages.  -  —  Appendicitis. —  Ovarian 
tumours.— Pibroid  tumours  of  uterus. — Surgical  operations. — Ague. — 
Syphilis.  —  Zymotic  diseases.  —  Yariola.  —  Scarlatina.  —  Measles.  — 
Erysipelas. — Enteric,  typhus,  and  relapsing  fevers.  —  Cholei-a      .         .     551 


CHAPTEE   XXIV. 

Premature  Expulsion  of  the  Ovum. 

Definition. — Mechanism.  -  Causation. — Symptoms  and  course. — Diagnosis. 
—  Prognosis.  —  Prophylaxis. — Treatment  of  threatened  abortion. — 
Treatment  of  inevitable  abortion. — Treatment  of  incomplete  abor- 
tion.— Treatment  in  later  months. — After-treatment   ....     566 


CHAPTEE  XXV. 

HjEMOREHAGE   in   PREGNiUS'CY. 

Menstruation  in  jaregnancy. — Placenta  prsevia.^Definition. — Causation. — 
Varieties. — Prequency. — Pathological  anatomy. — Source  of  the  blood. 
— Cause  of  bleeding  before  full  term. — Presentation  of  foetus. — 
Symptoms  and  course. — Diagnosis. — Prognosis. — Treatment. — ^Acci- 
dental haemorrhage.  -Causation. — Pathological  anatomy. — Symptoms 
and  course. — Diagnosis. — Prognosis. — Treatment         ....     590 


Table  of  Contents.  xiii 

CHAPTEE   XXVI. 

Precipitate  and  Prolonged  Labour. 

PAGE 

Precipitate  labour. — Treatment.— Prolonged  labour.— General  effects.- - 
Oontinuoti.s  action  of  uterus. — Retraction  of  uterus.— Effects  at  the 
several  stages. — Anomalies  of  expulsive  force. — Inertia  of  uterus. — 
Irregular  and  painful  contractions. — Inefficiency  of  auxiliary  forces. 
— Deviation  of  uterine  axis. —Treatment  in  first  stage  of  labour. — 
Treatment  in  second  stage. — External  pressure. — Oxytocic  drugs. — 
Forceps. —Indications  for  use  of  forceps 617 


CHAPTEE   XXVII. 

Labour  Obstructed  by  Anomalies  of  the  Soft  Parts. 

Trismus  uteri.  —  Causation. — Organic  rigidity  of  cervix. — Diagnosis. — 
Treatment.  —  Hydrostatic  dilators.  —  Manual  dilatation.  —  Instru- 
mental dilators.  —  Application  of  forceps.  —  Incision  of  cervix.— 
Version  or  craniotomy.— Vaginal  or  abdominal  Caesarean  section. — 
Atresia  of  cervix. — Malposition  of  os. — Cicatrices  and  atresia  of  vagina 
and  vulva. — Eigidity  of  perineum. — Cancer  of  cervix  uteri  and  pelvis. 
— Labour  complicated  by  tumours.  —  Fibroid  tumours.  —  Ovarian 
tumours.  —  Hydatid  tumours.  —  Prolapse  of  vagina.  —  Distended 
bladder.  —  Vesical  calculus. — Vaginal  enterocele.  —  Hsematoma  or 
tbrombus       ............     634 


CHAPTEE  XXVIII. 

Labour  Obstructed  by  Anomalies  of  the  Ovum. 

Shoulder,  arm,  and  transverse  presentations. — Freqiiency. — Causation. — 
Varieties.  —  Diagnosis.  —  Prognosis.  Natural  terminations. — Spon- 
taneous rectification. — Spontaneous  version. — Spontaneous  evolution. 
Spontaneous  expulsion. — Termination  of  neglected  cases. — Treat- 
ment. —  Version.  — ■  Decapitation. — Embryotomy.  —  Presentation  of 
head  or  arm  with  hea'd. — Dorsal  displacement  of  arm. — ^Presentation 
of  hands  and  feet  together. — Presentation  of  foot  with  head. — Locked 
twins.— Foetal  monstrosities. — Conjoined  twins. — Acardiac  monsters. — 
Anencephalic  monsters. — Extroversion  of  viscera. — Excessive  develop- 
ment of  foetus. — General  dropsy. — Emphysema. — Congenital  hydro- 
cejihalus. — Ascites,  hydrothorax,  distension  of  abdomen. — Congenital 
encephalocele. — Spina  bifida.— Other  external  tumours. — Anomalies 
of  membranes. — Shortness  of  funis 063 


xiv  Table  of  Contents. 

CHAPTEE   XXIX. 

Axo:malies  of  the  Pelvis. 

PAGE 

Enlarged  pelvis. — Contracted  pelvis. — General  forces  concerned  in  the 
production  of  pelvic  deformities. — Effect  of  the  pelvic  inclination. — 
Effect  of  standing,  walking,  &c. — Effect  of  sitting. — Diagnosis  of 
pelvic  contraction. — Pelvimetry. — External  meastirements. — Internal 
measiirements.— Yarieties  of  contracted  pelvis. — Classification. — The 
generally  contracted  pelvis. — The  infantile  pelvis. — The  rachitic 
generally  contracted  i)elvis. — The  masculine  pelvis. — The  dwarf  pelvis 
— The  flattened  pelvis  and  the  generally  contracted  flattened  jDelvis. — 
Caiisation. — The  rachitic  flattened  pelvis. — -The  chondrodystrophic 
pelvis. — Mechanism  of  labour. — Diagnosis. — -The  pelvis  of  double 
congenital  dislocation  of  the  hips. — The  split  pelvis.— General  effects 
on  pregnancy  and  labour. — Prognosis. — Treatment. — Choice  between 
forceps  and  version. — Extraction  of  after-coming  head. — Craniotomy 
and  Cfesarean  section. — Symphj-siotomj^  and  pubiotomy. — Induction 
of  ijremature  labovu-  or  abortion    ........     697 


CHAPTEE   XXX. 

Eare  Forms  of  Pelvic  Deformity. 

The  triradiate  or  rostrated  malacosteon  pelvis. — The  triradiate  rachitic 
I)elvis. — Oblique  pelvis. — The  scoliotic  pelvis. — The  obHque  pelvis  from 
shortening  or  disease  of  one  leg. — The  oblique  pelvis  of  Naegele. — 
Transversely  contracted  pelvis. — The  pelvis  of  Eobert. — The  kyphotic 
pelvis. — The  high  assimilation  pelvis. — The  bed-ridden  pelvis. — The 
siJondylolisthetic  pelvis. — Pelvis  deformed  by  out-growths  .         .         .     763 


CHAPTEE   XXXI. 

Induction  of  PREMATrRE  Labour  and  Artificial  Abortion. 

Induction  of  premature  labour. — Indications  for  the  operation. — Methods 
of  operating. — Puncture  of  membranes. — Introduction  of  flexible 
bougie  into  uterus. — Dilatation  of  cervix. — Hydrostatic  dilators. — The 
vaginal  douche. — Intra-uterine  injections. — Yaginal  tampons. — 
Choice  of  method. — Care  of  the  child. — Induction  of  artificial  abortion. 
— Indications  for  operation. — Choice  of  time. — Mode  of  operating        .     792 

CHAPTEE  XXXII. 

Extraction  of  the  Ecetus  in  Pelvic  Presentations. 

Causes  of  impaction. — Extraction  by  the  feet. — Bringing  down  the  leg  in 
breech  presentation. — Digital  traction. — The  soft  fillet. — The  blunt 
hook. — Eorceps. — Bringing  down  the  second  leg. — Liberation  of  the 
arms. — Delivery  of  the  head. — Injuries  to  the  foetus    ....     806 


Table  of  Contents.  xv 

CHAPTER  XXXIII. 

The  Forceps  and  Vectis. 

PAGE 

The  vectis. — The  vectis  in  occipito -posterior  i)ositions. — The  forcei^s. — 
"  Historjr. — Mechanical  action. — Requirements  of  good  forceps. — 
Varieties. — Disadvantages  and  advantages  of  straight  forceps. — Axis- 
traction  forcei)s. — Application  of  torcejis. — Axis  traction  with  long 
curved  forceps. — Leverage  action  of  forceps. — Application  of  axis- 
traction  forceps. — Forceps  in  occipito-posteiior  presentations. — Forceps 
in  face  presentations. — Application  of  forceps  to  after-coming 
head 821 


CHAPTER   XXXIV. 

Version. 

Definition. — History.— Cephalic  version. — Cephalic  version  by  external 
method. — Cephalic  version  by  combined  external  and  internal 
method. — Podalic  version. — Bipolar  version  in  head  presentation. — • 
Bipolar  version  in  shoulder  presentation. — Internal  version  in  head 
presentation. — Internal  version  in  shoulder  presentation. — Choice  of 
leg  to  seize. — -Application  of  noose  to  prolapsed  arm.— Version  in 
impacted  shoulder  presentation     .         .         .         .         .         .         .         .861 


CHAPTER   XXXV. 

Craniotomy  and  Embryotomy. 

Indications  for  operation. — Mortality. — Instruments. — Method  of  operating. 
— Methods  of  extraction. — Craniotomy  forceps. — The  cephalotribe.— 
Cranioclasm. — Induction  of  face  presentation. — Version. — The  crochet. 
— Forceps.— Extraction  of  body. — Perforation  of  after-coming  head. — 
Embryotomy  in  pelvic  presentations     .......     883 


CHAPTER   XXXVI. 

CESAREAN  Section,  Symphysiotomy,  and  Pubiotomy. 

Cajsarean  section. — History. — Indications  for  operation. — Time  for 
f)perating. — The  operation. — Uterine  sutures.  — After-treatment. — 
]*]xtra-peritoneal  Ctesarean  section. — Post-mortem  Ceesarean  section.— 
I'orro's  operation. — Supra- vaginal  hysterectomj'. — -Panhysterectomy. — 
Vaginal  Ciosarean  section. — SJ'mphysiotomJ^^ — History. — Indications 
for  opoi'utioii . — I'ro]iaTations. — The  operation. — Prognosis.  — Puljiotomy     908 


xvi  Table  of  Contents. 

CHAPTEE   XXXVII. 

Accidents  during,  and  after  Labour. 

PAGE 

Euptures  and  lacerations  of  genital  canal. — Eupture  of  uterus  or  vaginal 
involving  peritoneum. — Eupture  during  pregnancy. — Incomplete 
rupture  of  uterus. — Perforation  of  the  uterus. — Lacerations  of  cervix. 
— Lacerations  of  the  vagina. — Lacerations  of  the  vaginal  outlet, 
vulva,  and  perineum. — Eupture  of  the  pelvic  articulations. — Obstetrical 
paralysis. — Presentation,  prolapse  and  expression  of  the  funis. — 
Physometra  or  tympanites  uteri. — Inversion  of  uterus         .         .         .     934 


CHAPTEE  XXXVIII. 

Eetention  of  the  Placenta  and  Post-partum  HiEMORRiiAGE. 

Eetention  of  the  placenta.— Causation. — Inertia. — Adhesion. — Hour-glass 
contraction. — Prophylaxis. — Treatment. — Post-partum  htemorrhage. 
— Frequency.— Causation.— Symptoms  and  diagnosis. — Prophylaxis. 
— Treatment. — Intravenous  injection  of  saline  fluid. — Secondary 
puerperal  haemorrhage  .........     973 


CHAPTEE   XXXIX. 

Puerperal  Fevers. 

Definition. — Organisms  in  puerperal  fever. — Varieties — Causation. — Eela- 
tions  to  erysipelas  and  scarlatina. — Contagious  character  of  different 
varieties. — Pathological  anatomy. — Symptoms  and  course. — General 
peritonitis. — Saprtemia. — Vascular  or  phlebitic  septicaemia. — Pyeemia. 
— Pelvic  cellulitis  and  pelvic  peritonitis. — Frequency. — Prognosis. — 
Prophylaxis. — Prophylaxis  in  lying-in  hospitals. — Treatment. — Treat- 
ment of  pelvic  cellulitis  and  pelvic  peritonitis. — Operative  measures. — 
Puerperal  tetanus 992 


CHAPTEE  XL. 

Phlegmasia  Dolens,  Thrombosis,  Embolism,  Sudden  Death, 
Chorion  Epithelioma. 

Phlegmasia  dolens  or  peripheral  venous  thrombosis. — Embolism  and 
thrombosis  of  pulmonary  arteries. — EmboHsm  of  systemic  arteries. — 
Entrance  of  air  into  the  veins. — Syncope  and  shock.  —Other  causes  of 
sudden  death. — Chorion  epithelioma  or  deciduoma  malignum      .         .1048 


Table  of  Contents.  xvii 

CHAPTER   XLI. 

Puerperal  Insanity. 

PAGE 
Insanity  of  pregnancy. — Insanity  of  labour. — Insanity  of  the  puerperal 

period.- — -Insanity  of  lactation. — Prophylaxis. — Treatment  .         .         .  1070 


CHAPTER  XLII. 

Injuries  and  Diseases  of  the  Fcetus, 

CephalliEematoma. — Other  injuries  to  the  head. — Injuries  to  the  bones. — 
Injuries  to  nerves. — Cerebral  hteniorrhages. — Il£ematoma  of  the 
sterno-mastoid. — Asphyxia  neonatorum. — Mastitis  neonatorum. — 
Ophthalmia  neonatorum. — Tightness  of  frenum  linguae. — Tetanus 
neonatorum. — Icterus  neonatorum. — Septic  infections  of  the  new- 
born      1079 


CHAPTER  XLIII. 

Diseases  oe  the  Breast. 

Abnormalities  in  the  quantity  of  milk. — Deficient  secretion  of  milk. — 
Polygalactia.— Galactorrhoea. — Dej^ressed  nipples. —Excoriations  and 
fissures  of  nipples.— Mastitis,  mammary  abscess. — Galactocele    .         .1103 


INDEX       .         : 1113 


List  of  Illustrations 


FIGURE 

1.  Os  Innorainatum  ....... 

2.  Division  between  the  Ilium,  Ischium,  and  Pubes  . 

3.  Sacrum  and  Coccyx     ....... 

4.  Section  of  Sacrum  and  Coccyx        ..... 
0.  Female  Pelvis,  seen  from  the  front     .... 

6.  Pemale  Pelvis,  viewed  in  the  Axis  of  the  Brim 

7.  Outlet  of  Pelvis 

8.  Male  Pelvis,  seen  from  the  front    ..... 

9.  Male  Pelvis,  viewed  in  the  Axis  of  the  Brim 

10.  Pelvis  of  Chimpanzee      ....... 

11.  Antero-posterior  Section  of  Pelvis       .... 

12.  Nutation  of  Sacrum  during  Parturition  ....... 

13.  Antero-posterior  Section  of  Sacrum  and  Symphysis  Pubis  to  show 

Effect  of  Walcher's  position     ........ 

Section  through  outlet  of  Pelvis  to  show  Effect  of  Walcher's  position 

Section  of  Pelvis,  parallel  to  the  Brim,  passing  through  the  points 
where  the  Pelvis  rests  upon  the  Heads  of  the  Femora         .         .     . 

Section  through  Plane  of  Pelvic  Brim         ...... 

Section  through  Plane  of  greatest  dimensions  .         .         .         .     . 

Section  through  Plane  of  least  dimensions  ...... 

Section  of  Pelvis,  side  to  side  ;  perpendicular  to  Plane  of  Brim  . 
20.  Lateral  view  of  Pelvis  from  within,  showing  the  inclined  Planes  of 
the  Ischium  ........... 

Diagram  to  show  asymmetry  of  Pelvic  Brim       ..... 

Diagram  showing  Axis  and  Planes  of  Pelvis  .         .         .         .         .     . 

Pelvis  of  Foetus,  viewed  in  the  Axis  of  the  Brim         .         .         .         . 

Antero-posterior  Section  of  Adult  Pelvis,  with  Foetal  Pelvis  super- 
imposed      ............ 

25.  Diagram  to  illustrate  the  Change  of  Shape  in  the  Pelvis     . 

26.  Transverse  Section  through  Ovary,  Mesosalpinx  and  Fallopian  Tube 

27.  Section  of  Ovary  of  Human  Foetus         ....... 

28.  Section  of  Ovary  of  Foetus  of  Eight  Months 

29.  Section  of  Adult  Human  Ovary 

30.  Section  of  Ovary  of  Woman  aged  Twenty-five  Years  .... 

31.  Section  of  a  portion  of  Cat's  Ovary 

32.  Section  of  Wall  of  Grraafian  Follicle 

33.  Section  of  Graafian  Follicle 

34.  Human  Ovum     ........... 

35.  (!omposite  Drawing  of  Mucous  Membrane  of  Uterus   renKjved  hy 

Hysterectomy  on  first  day  of  Menstruation  .         .         ... 

b2 


14. 
15. 

16. 
17. 

18. 
19. 


21. 
22. 
23. 
24. 


PAGE 
2 

2 
3 

3 
3 
4 
4 
6 
6 
7 
8 
10 

11 
12 

13 
14 
15 
16 

17 

18 
19 
21 
24 

25 
27 
34 
35 
36 
37 
38 
39 
40 
41 
42 

47 


XX  List  of  Illustrations. 

FIGURE  PAGE 

36.  Oblique  Section  througli  Ovary  and  Tube  in  situ        ....       53 

37.  Section  of  Corpus  Luteum  of  Pregnancy,  showing  Lutein  Cells 

38.  Section  of  Wall  of  Corpus  Luteum      ...... 

39.  Section  of  Human  Ovary,  showing  Corpus  Luteum  at  Third  Month 

of  Gestation 

40.  Corpus  Luteum  at  Full  Term  of  Pregnancy 

41.  Diagram  of  the  Formation  of  the  Corpus  Luteum . 

42.  Formation  of  Polar  Bodies  in  Asterias  Grlacialis  . 

43.  Formation  of  Second  Polar  Body  of  the  Mouse 

44.  Segmentation  of  Mammalian  Ovum    . 

45.  Stages  in  the  Fertilisation  of  the- Egg  of  the  Mouse 

46.  Diagram  of  Fertilisation      ..... 

47.  Diagram  of  Embedding  of  Ovum  and  Formation  of  Decidua  Capsu- 

laris  and  Basalis  ...... 

48.  Pregnant  Uterus,  showing  very  Early  Ovum  embedded  in  posterior 

wall         ........ 

49.  Section  through  centre  of  Peters'  Ovum 

50.  Decidual  Cells  from  early  Pregnancy 

51.  Section  of   Ovum  in  situ   at   beginning  of  Second  Week,  showing 

Decidua  Capsularis  formed  ..... 

52.  The  same  Ovum  magnified 

53.  Membranes  in  situ,  from  near  margin  of  Placenta 

54.  Section  of  Decidua  Yera  at  Fourth  Month 

55.  Transverse  Section  of  Embryonic  Area  of  Sheep    . 

56.  Embryonic  Area  of  the  Eabbit    .... 

57.  Scheme  of  Formation  of  the  Amnion 

58.  Diagrammatic  Transverse  Sections  to  illustrate  Cleavage  of  Mesoderm 

and  Formation  of  Amnion        .... 

59.  Diagrams  to  illustrate  the  Formation  of  Allantois  in  some  Mam- 

mals   ......... 

60.  Diagram  of  Early  Ovum  to  show  Origin  of  Mesoderm 
6L  Embryonic  Area  in  Peters'  Ovum  .... 

62.  Embryo  of  2  mm 

63.  Section  of  Spee's  Human  Ovum      .... 

64.  Spee's  Human  Ovum  at  early  part  of  Second  Week    . 

65.  Sagittal  Section  of  Early  Human  Ovum 

66.  Development  of  Placenta 

67.  Embedding  of  Early  Guinea-pig  Ovum 

68.  Development  of  Placenta,  diagrammatic 

69.  Vertical  Section  through  the  Decidua  Basalis  at  the  Sixth  Week 

70.  Very  Early  Human  Ovum,  of  Age  not  exceeding  Fourteen  Days 

71.  Diagram  of  Teacher-Bryce  Ovum 

72.  Human  Ovum  of  Eighth  Week 

73.  Diagram  of  Embedding  of  Early  Htiman  Ovum 

74.  Section  through  Placenta  of  Seven  Months  in  situ 

75.  Diagram  showing  the  Mode  of  Attachment  of  the  Villi  tc  the  Decidua 

76.  Chorionic  Villi 

77.  Sections  of  Chorionic  Villi 

78.  Section  of  fully-formed  Placenta,  with  part  of  the  Uterus 

79.  Diagrammatic  Section  of  Placenta 


List  of  Illustrations.  xxi 

FIGURE  p^jjg 

80.  Uterine  Surface  of  Placenta jq^ 

81.  Eoetal  Surface  of  Placenta       .         .         .         .         .         .         .         .     .     106 

82.  Early  Ovum,  in  the  Museum  of  Guy's  Hospital,  showing  the  straight 

direction  of  the  Vessels  of  the  Cord HO 

83.  Microscopic  Section  of  Wharton's  Jelly HI 

84.  Section  of  Umbilical  Cord        .         .         .         .         .         .         .         ..112 

85.  Diagrams  illustratmg  the  Formation  of  the  Umbilical  Cord        .         .11,3 

86.  Early  Human  Ovum  iHst^it   .         .         .  .         .         .  .  .     .     116 

87.  Series  of  Embryos        .         .         .         ...         .         .  .         .117 

88.  Diagram  of  the  Foetal  Circulation 122 

89.  Foetal  Skull .     128 

90.  Foetal   Skull,    seen    from   above,    showing    anterior    and    posterior 

Fontanelles  .         .         .  .         .  .         .         .         .         .     .     129 

91.  Foetal  Skull,  posterior  view,  showing  posterior  Fontanelle,  Sagittal 
and  Lambdoidal  Sutures.         .         .         .         .         .         .         .         .129 

.     .  133 

.  133 

.     .  136 

.  137 

.     .  138 

.  140 

.     .  141 

.  141 


92.  Skull  of  a  European  Foetus     ...... 

93.  Skull  of  a  Negro  Foetus 

94.  Attitude  of  the  Mature  Foetus  in  titer o   .... 

95.  Normal  Attitude  of  the  Foetus  in  ntero 

96.  Attitude  of  Foetus  in  ntero  with  abundant  Liquor  ximnii 

97.  Outline  of  the  Uterus  at  Full  Term    .... 

98.  Ovoid  Form  of  Foetus  at  Full  Term        .... 

99.  Adaptation  of  Foetus  to  Uterus 

100.  Adaptation  of  Hydrocephalic  Foetus       . 142 

101.  Maladaptation  of  Foetus  and  Uterus  in  Breech  Presentation       .         .     142 

102.  Foetus  in  utero  at  Fifth  Month        ........     1-13 

103.  Development  of  Muscular  Fibre  Cells  of  Gravid  Uterus     .         .         .146 

104.  Drawing  of  Elastic  Fibres  in  "Wall  of  Pregnant  Uterus  .         .     .     147 

105.  External  Layer  of  Muscle  Fibres  of  Uterus 147 

106.  Middle  Layer  of  Muscle  Fibres  of  Uterus 147 

107.  Internal  Layer  of  Muscle  Fibres  of  Uterus 148 

108.  Arteries  and  Veins  of  Uterus  .........     149 

109.  Sagittal  Section  of  Gravid  Uterus  of  Fourth  Month    ....     151 

110.  Sagittal  Section  of  Pregnant  Uterus  at  Eighteenth  Week       .         .     .     152 

111.  Level  of  Fundus  Uteri  at  Different  Weeks  of  Pregnancy    .         .         .153 

112.  Sagittal  Section  of  Uterus  and  Child  at  end  of  Pregnancy      .         .     .     154 

113.  Diagram  of  Uterus  showing  the  Segments  and  the  Ring  of  Bandl      .     156 

114.  Diagram  to  illustrate  apparent  Shortening  of  Cervix,  without  any 

Shortening  of  Cervical  Canal       ........     159 

115.  Cervix  a,t  Seventh  Month  of  Pregnancy 160 

116.  Head  Engaged  in  Pelvic  Brim  at  Full  Term 161 

117.  Mammary  Changes  in  the  Later  Months  of  Pregnancy,  with  Forma- 

tion of  Secondary  Areola .         .         .         .         .         .         .         .         .164 

118.  Method  of  Bimanual  Examination  of  Uterus 174 

119.  Frozen  Section  of  a  Uterus  at  Thirteenth  Week  of  Pregnancy    .         .175 

120.  Coronal  Section  of  a  Pregnant  Uterus  at  the  Twelfth  Weel^   .         .     .     176 

121.  Sagittal  Section  of  a  Pregnant  Uterus  at  the  Fourth  to  the  Fifth 

Week  of  Pregnancy  .         .         .         .         .         .         .         .         .177 

122.  JJemonstration   of    Hogar's   Sign   by   Bimanual    Examination,   the 

Uterus  being  antevorted      .........     178 


xxii  List  of  Illustrations. 

FIGURE  PAGE 

123.  Demonstration   of    Hegar's   Sign   by   Bimanual    Examination,    tlie 

Uterus  being  retroverted         .         .         .         .         .         .         .         .179 

124.  Diagram  stowing  the  Areas  in  wbicb  the  Foetal  Heart  Sounds  are 

heard  with  greatest  intensity        .         .         .         .         .         .         .     .  187 

125.  Mode  of  measuring  the  Height  of  the  Fundus  Uteri  with  Callipers    .  199 

126.  Diagram  of  Nerves  of  Uterus 208 

127.  Diagram  of  Curve  of  Pains  of  First  Stage       .         .         .         .         .     .  210 

128.  Diagram  showing  Shortening  and  Thickening  of  Muscle  Fibres          .  211 

129.  Diagram  of  Dilatation  of  Cervical  Canal  in  a  Primipara      .         .         .  217 

130.  Diagram  of  Dilatation  of  Cervical  Canal  in  a  Multiparoe         .         .     .  218 

131.  From  a  Frozen  Section  of  a  Patient  who  died  in  Labour,  the  Head 

having  entered  the  Pelvic  Cavity,  but  the  Membranes  being  yet 
unruptured      .         .  .  .         .  .         .         .         .         .         .220 

132.  From  the  same  Section  as  Fig.  131,  the  Foetus  being  removed       .     .  221 

133.  Diagram  showing  separation  of  Anuiion  from  the  Placenta         .         .  222 

134.  Vertical  Section,  to  illustrate  the  relations  of  the  Uterus  and  Vagina 

in  the  Virgin,  the  Bladder  being  nearly  empty  .....  224 

135.  Tracing  of  the  Uterine  Pains  during  the  Exj)ulsive  Efforts  of  the 

Second  Stage  ...........  226 

136.  Appearance  of  Vertex  at  Vulval  Outlet  .         .         .         .         .         .     .  227 

137.  Emergence  of  Foetal  Head  at  Vulval  Outlet 228 

138.  Diagram  of  General  Intra-uterine  Pressure  .         .         .         .         .     .  231 

139.  The  Cavity  of  the  Uterus,  with  the  Parturient  Canal  in  a  state  of  Full 

Dilatation 232 

140.  Sagittal  Section  of  Primipara  at  beginning  of  First  Stage  of  Labour .  233 

141.  Sagittal  Section  of  Uterus  from  near  end  of  Second  Stage  of  Labour  234 

142.  Section  of  Litems  with  Child  in  situ,  towards  end  of  Second  Stage  of 

Labour        ............  236 

143.  Superficial  and  Deep  Muscles  of  Pelvic  Floor  seen  from  below  .         .  237 

144.  Lateral  View  of  Muscles  of  Pelvic  Floor 238 

145.  Brim  of  the  Pelvis,  and  Base  of  the  Foetal  Skull  in  first  cranial 

position  ............  240 

146.  Brim  of  the  Pelvis,  and  Base  of  the  Foetal   Skull  in  the  second 

position    ............  240 

147.  Brim  of  the  Pelvis,  and  Base  of  the  Fo'tal  Skull  in  the  third  position  241 

148.  Brim  of  the  Pelvis,  and  Base  of  the  Foetal  Skull  in  the  fourth  position  241 

149.  First  Vertex  Presentation 242 

150.  Second  Vertex  Presentation        ........  242 

151.  Third  Vertex  Presentation 243 

152.  Fourth  Vertex  Presentation 243 

153.  Diagram  showing  that  with  the  Head  completely  flexed  the  Maximum 

Diameter  is  coincident  with  the  Axis  of  the  Plane  of  the  Pelvis  in 

which  the  Head  is  lying      .........  245 

154.  Line  of  Section  and  Shape  of  Suboccipito-bregmatic  and  of  Occipito- 

frontal Planes 246 

155.  Diagram  of  Head-lever  ..........  247 

156.  Diagram  to  illustrate  the  Mode  in  which  Flexion  is  produced  by  the 

Pressure  of  the  Girdle  of  Contact  on  the  Head         ....  248 

157.  Diagram  to  illustrate  the  Li crease  of  Flexion  by  Pressure,  after  the 

Head  has  entered  the  Genital  Canal 249 


List  of  Illustrations.  xxiii 


158.  Outline  of  the  Internal  Surface  of  the  left  half  of  the  Pelvis,  showing 

the  path  of  the  Occiput  in  the  first,  and  in  the  occipito-anterior 
termination  of  the  fourth  position   .......     249 

159.  Diagram  of  Mechanism  of  Labour  .......     250 

160.  Showing  the  Genital  Tract  toward  the  end  of  the  Second  Stage  of 

Labour    ............     252 

161.  Commencement  of  Extension,  showing  position  of  Foutanelles     .     .     254 

162.  First  Stage  of  Extension 255 

163.  Second  Stage  of  Extension     .........     255 

164.  Successive  Stages  of  first,  or  left  occipito-anterior,  position  of  Vertex     257 

165.  Escape  of  Head  by  Flexion  in  unreduced  occipito-posterior  position. 

First  Stage 258 

166.  Escape  of  Head  by  Flexion  in  unreduced  occipito-posterior  position. 

Second  Stage 258 

167.  Diagram  of  Mechanism  of  Labour  in  unreduced  occipito-posterior 

Presentations  ...........     258 

168.  Successive  Stages  of  fourth,  or  left  occipito-posterior,   j^osition   of 

Vertex,  when  unreduced     .........     259 

169.  Plane  of  Section  and  Shape  of  suboccipito-frontal  Diameter       .         .     260 

170.  Diagram  of  Head  presenting  at  Brim  in  occipito-posterior  Presenta- 

tion   261 

171.  Section  showing  Partial  Extension   of  Saline  when  the  Occiput  is 

behind 262 

172.  Outlet  of  the  Pelvis,  showing  a  slight  Naegele- obliquity  of  the  Foetal 

Head,  which  is  passing  through  the  Pelvic  Cavity  in  the   first 
position 263 

173.  Outlet  of  the  Pelvis,  showing  a  slight  Naegele -obliquity  of  the  Fcetal 

Head,  which  is  passing  through  the  Pelvic  Cavity  in  the  third 
position         ............     264 

174.  Foetus  from  a  case  of  Advanced  Pregnancy,  showing  inclination  of 

Head  towards  Eight  Shoulder 264 

175.  Diagram  to  show  Synclytism  of  the  Head       .         .         .         .         .     .     265 

176.  Diagram  of  Anterior  Parietal  Obliquity 266 

177.  Diagram  of  Posterior  Parietal  Obliquity  .         .         .         .         .     .     267 

178.  Moulding  of  Head  in  occipito-anterior  position  of  Vertex  .         .         .     268 

179.  Moulding  of  Head  in  occipito-anterior  position  of  Vertex        .        .     .     269 

180.  Usual  Moulding  of  Head  in  unreduced  occipito-posterior  position  of 

Vertex         ............     270 

181.  Usual  Moulding  of  Head  in  unreduced  occipito-posterior  ijosition  of 

Vertex 270 

182.  Diagram  showing  positions  of  Centre  of  Caput  Succedaneum  in  the 

several  positions  of  the  Vertex    ........     272 

183.  Abdominal  Palpation,  Manoeuvre  No.  1 274 

184.  Abdominal  Palpation,  Manoeuvre  No.  2  ......     275 

185.  Abdomijial  Palpation,  Manoeuvre  No.  3 276 

186.  Abdominal  Palpation,  Manoeuvre  No.  4  ......     277 

187.  First  Vertex  position 278 

188.  Second  Vertex  positioii  .........     278 

189.  Third  Vertex  position 279 

190.  Fourth  Vertex  position 279 


xxiv  List  of  Illustrations. 

FIGUEE  PAGE 

191.  Moulding  of  Bones  of  Head 280 

192.  Sagittal  Section  showing  Placenta  in  titer o  after  Birth  of  Child      .     .  282 

193.  Expulsion    of  Placenta  from  Upper  Uterine   Segment  into  Lower 

Uterine  Segment  and  Vagina           .......  284 

194.  Delivery  of  Placenta  according  to  Matthews  Duncan     .         .         .     .  286 

195.  Delivery  of  Placenta  according  to  Schultze          .....  286 

196.  Examination  of  the  Os  Uteri  in  the  First  Stage  of  Labotu-    .         .     .  296 

197.  Supporting  the  Perineum    .........  303 

198.  Expulsion  of  Shoulders 304 

199.  Presentation  of  the  Face  at  the  Pelvic  Brim  in  the  second  facial  position  321 

200.  Diagram  of  the  Head  completely  extended  entering  the  Pelvic  Inlet  .  322 

201.  Diagram  of  Head-lever  in  Face  Presentation            .         .         ...  323 

202.  Diagram  to  show  the  Eifect  of  Obliquity  of  the  Uterus  in  causing 

Face  Presentations  ..........  324 

203.  Potation  of  Chin  under  Pubic  Arch  in  Face  Presentation      .         .     .  327 

204.  Distension  of  intact  Perineum  in  Face  Presentation            .         .         .  328 

205.  Passage  of  Head  under  Pubic  Arch  by  a  movement  of  Flexion  in  Face 

Presentation     ...........  329 

206.  Arrest  of  Head,  Neck,  and  Shoulders  in  Plane  of  Bi'im  in  persistent 

mento-posterior  Presentation       ........  330 

207.  Diagram  of  Mechanism  of  Labour  in  Face  Presentation    .         .         .  332 

208.  Successive  Stages  of  first,  or  right  mento-posterior,  position  of  Face.  333 

209.  Diagram  of  Mechanism  of  Labour  of  second  Face  Presentation     .     .  334 

210.  Moulding  of  Head  in  Face  Presentation 335 

211.  Moulding  of  Head  in  Face  Presentation 335 

212.  Face  Presentation,  first  and  second  positions      .....  336 

213.  Face  Presentation,  third  and  fourth  positions          .         ....  337 

214.  Plane  of  Section  and  Shape  of  Mento-vertical  Diameter     .         .         .  338 

215.  Moulding  of  Head  in  Brow  Presentation         .         .         .         .         .     .  340 

216.  First,  or  left  sacro-anterior,  position  of  the  Breech    ....  345 

217.  Foetus  i»  ifiero  with  Breech  Presentations      .         .         .         .         .     .  346 

218.  Breech  Presentation  with  extended  Legs     ......  347 

219.  Breech  in  Pelvis,  left  sacro-anterior  Presentation,  seen  from  below  .  349 

220.  Breech  in  Pelvis,  right  sacro-posterior  Presentation,  seen  from  below  350 

221.  Passage  of  Breech  under  Pubic  Arch  by  a  movement  of  lateral  Flexion  351 

222.  Passage  of  the  Shoulders  in  Pelvic  Presentation          .         .         .         .  352 

223.  Diagram  of  Mechanism  of  Breech  Pi'esentations    .....  353 

224.  Passage  of  the  Shoulders  in  Pelvic  Presentation,  one  Arm  extended  .  354 

225.  Descent  of  the  Head        ..........  355 

226.  Diagram  of  Mechanism  of  Labour  in  Foot  or  Ivnee  Presentation        .  356 

227.  Manual  Extraction  of  Head  through  the  Outlet  of  Soft  Parts        .     .'  360 

228.  Shoulder  and  Jaw  Traction 362 

229.  Twins  in  ntero,  both  presenting  by  Vertex      .          .         .         .         .     .  366 

230.  Diagram  of  the  Ari-angement  of  the  Placentae  and  Membranes  with 

Uniovular  Twins      ..........  368 

231.  Acardiac  Acephalic  Foetus 369 

232.  Section  of  a  Placenta  with  a  Foetus  Compressus         ....  370 

233.  Adaptation  of  Twins  in  vtero,  both  lying  transversely   .         .         .     .  371 

234.  Adaptation  of  Twins  in  utero,  with  one  Vertex  and  one  Pelvic  Pre- 

sentation         ...........  372 


List  of  Illustrations.  xxv 

FIGURE  PAGE 

235.  Adai)tation  of  Twins  in  ntero,  both  pi'esentiug  by  the  Vertex          .     .  373 

236.  Uterus  Didelphys •         ...  375 

237.  Uterus  Septus,  with  Septate  Vagina       .......  376 

238.  Uterus  Subsej^tus        ..........  376 

239.  Uterus  Bicornis  Unicollis 377 

240.  A  Twin  Pregnancy 378 

241.  Section  of  a  Uterus  from  a  Patient  djnugfive  mimites  after  Delivery  384 

242.  Section  of  Uterus  on  the  Third  Day  of  the  Piierperium       .         .         .  385 

243.  Section  of  Uterus  on  the  Sixth  Day  of  the  Puerperium          .         .     .  386 

244.  Section  of  the  Uterus  on  the  Twentj^-sixth  Day  of  the  Puerperium  .  388 

245.  External  Views  of  the  Nulliparous  and  Parous  Uterus           .         .     .  397 

246.  Sections  of  the  Nulliparous  and  Parous  Uterus 398 

247.  Chart  showing  Involution  of  Uterus,  Average  of  Thirty-four  Cases  .  405 

248.  Chart  showing  Involution  of  Uterus.      Saprcemia.      Effect   of  one 

Douche,  and  clearing  out  Uterus    .......  405 

249.  Hawksley's  Milk  Steriliser 412 

250.  Tubal  Pcetation,  with  the  Corpus  Luteum  in  the  Ovary  of  the  opposite 

side 419 

251.  Ovarian  Pregnancy          ..........  421 

252.  Early  Tubal  Pregnancy  unruptured,  situated  in  Isthmus  of  Tube        .  422 

253.  Tubal  Eoetation  showing  intra-mural  Site  of  Ovum  outside  Lumen  of 

Tube 423 

254.  A  Tubal  Mole  seen  in  Section 424 

255.  Specimen  of  Tubal  Abortion  .........  425 

256.  Tubal  Eoetation,  Decidua  in  Uterus  partly  separated          .         .         .  426 

257.  Early  Ruptured  Ampullary  Pregnancy  .......  427 

258.  Tubo-uterine  or  Interstitial  Eoetation          ......  430 

259.  Intra-ligamentous  Eoetation    .........  431 

260.  Uterus  and  Foetus  from  a  Case  of  (?  secondary)  Abdominal  Eoetation.  432 

261.  The  Author's  Case  of  Primary  Abdominal  Eoetation  ....  435 

262.  Pregnancy  in  Rudimentary  Uterine  Horn      .         .         .         .         .     .  436 

263.  Foetus  retained  Twenty  Tears  in  Calcified  Broad  Ligament  Sac          .  439 

264.  Decidual  Cast  from  Case  of  Tubal  Pregnancy         .         .         .         .     .  441 

265.  Degenerate  Villi  in  Wall  of  Tube 443 

266.  Mikulicz  Tampon 452 

267.  Kidney  of  Pregnancy  from  Patient  with  Albuminuria        .         .         .  469 

268.  Kidney  from  a  Case  of  Eclampsia           .......  479 

269.  Liver  from  a  Patient  dying  of  Eclampsia    ......  480 

270.  Position  of  Uterus  with  a  Pendulous  Abdomen      .         .         ...  494 

271.  Incarceration  of  the  retroflexed  Gravid  Uterus  with  Piupture  of  the 

Bladder 497 

272.  Incomplete  Eetroflexion  of  the  Uterus  .......  500 

273.  Prolajjse  of  second  degree  in  unimpregnated  Uterus  .         .         .         .  505 

274.  Prolajjse  of  third  degree  in  unimpregnated  Uterus         .         .         .     .  506 

275.  Battledore  Placenta     .         .         .         .         .         .         .         .         .         .512 

276.  Placenta  Succentuin'ata  .         .         .         .         .         .         .         .         ..513 

277.  Placenta  Circumvallata        .........  513 

278.  Blighted  Ovum  with  irregular  thickening  of  Membranes        .         .     .  5i4 

279.  Villi  from  Syphilitic  J'laccnta 516 

280.  Tuberous  Fleshy  M(jle 518 


xxvi  List  of  Illustrations. 

FIGURE  PAGE 

281.  Blighted  Ovum,  showing  Morbid  Enlargement  of  the  Umbilical  Cord  519 

282.  Section  of  Placental  Tissue  from  an  Early  Ovum  retained  Eour 

Months  in  utero  after  Death  of  Embryo          .....  520 

283.  A  portion  of  the  Section  shown  in  Fig.  282,  more  highly  magnified    .  520 

284.  Hydatidiform  Degeneration  of  Chorion           .         .         .         .         .     .  523 

285.  Commencement  of  Hydatidiform  Degeneration  of  Chorion          .         .  523 

286.  VniiofMole  .         / 524 

287.  Uterus  containing  a  Yesicular  Mole  .......  527 

288.  Section  of  Uterine  Wall  and  Tart  of  Mole 529 

289.  Placenta  Yelamentosa 535 

290.  Knot  of  Umbilical  Cord 536 

291.  Coiling  of  Cord  round  Neck  of  Foetus 537 

292.  Torsion  of  the  Cord 538 

293.  Spirochaeta  Pallida  from  Blood  Smear         .         .         .         .         .         .541 

294.  Tibia  from  a  healthj'  and  syphilitic  Foetus      .         .         .         .         .     .  542 

295.  Shrunken  Foetus  after  Eetentiou  in  utero   ......  547 

296.  Contents  of  Cyst,  in  Dr.  Oldham's  Case  of  Missed  Labour      .         .     .  548 

297.  Usual  Mechanism  of  Abortion  in  the  first  Two  Months  of  Pregnancy.  567 

298.  Mechanism  of  Abortion  in  the  Early  Months 567 

299.  Abnormal  Mechanism  of  Abortion      .......  568 

300.  Mechanism  of  Abortion,  Foetus  expelled  in  the  intact  Amnion      .     .  568 

301.  Foetus   expelled  entire   with   the  Membranes  and  Placenta  at  the 

Seventh  Month        ..........  573 

302.  Ovum  expelled  in  Abortion  in  Third  Month 576 

303.  Evacuation  of  the  Uterus  in  a  Case  of  Early  Abortion        .         .         .  583 

304.  i^uthor's  Uterine  Yulsellum 584 

305.  Ovum  Forceps     ...........  585 

306.  Irrigating  Curette  ...........  587 

307.  Sim's  Cm-ette 587 

308.  Placenta  Prsevia 592 

309.  Diagram  of  Eeflexal  iJevelopmcnt  of  I'lacenta 593 

310.  Central  Placenta  Prrevia 595 

311.  Marginal  Placenta  Prsevia  and  Low  Implantation  of  the  Placenta      .  595 

312.  Placenta  Prtevia,  nndistiirbed  by  any  commencement  of  Labour       .  596 

313.  Champetier  de  Eibes'  Bag  in  situ    ........  604 

314.  Half  Breech  Forming  a  Plug  after  Version  in  a  case  of  Placenta 

Prasvia 606 

315.  Section  of  the  Uterus  of  a  Patient  who  died  of  internal  and  external 

Hfemorrhage         ...........  609 

316.  Section  of  the  Uterus  of  a  Patient  dying  at  the  Eighth  Month  from 

Eclampsia  .         .         .         .         .         .         .         .         .         .         .611 

317.  Section  of  a  Portion  of  the  L^terine  Wall  and  Vagina  from  a  Patient 

dying  during  Labour      ..........  622 

318.  Improved  Hydrostatic  Dilator  for  Cervix  Uteri 637 

319.  Champetier  de  Eibes'  Hydrostatic  Dilator,  with  Forceps  for  introduc- 

tion         639 

320.  Frommer's  Uterine  Dilator 642 

321.  Bossi's  Uterine  Dilator            642 

322.  Uterus  removed  by  Wertheim's  Operation  in  a  Case  of  Cancer  of  the 

Cervix  obstructing  Delivery      ....,.,,  650 


List  of  Illustrations.  xxvii 

FIGURE  PAGE 

323.  Eetroflexion  of  the  Pregnant  Uterus  at  Full  Term  with  a  Fibromyoma 

adherent  in  Douglas'  Pouch           ........  655  • 

324.  Dermoid  Tumour  of  the  Right  Ovary  obstructing  Labour  .         .         .  657 

325.  Prolapse  of  posterior  Vaginal  Wall  with  Enterocele        .         .         .     .  660 

326.  Coronal  Section  of  the  Pelvis,  showing  the  usual  position  of  a  Hfoma- 

toma  of  the  Vulva 661 

327.  Arm  Presentation  in  the  dorso-anterior  position     .         .         ...  664 

328.  Arm  Presentation  in  the  abdomino-anterior  position  ....  666 

329.  Commencement  of  Spontaneous  Evolution      .         .         .         .         .     .  670 

330.  Spontaneous  Evolution  arrested           .......  671 

331.  Further  Progress  of  Spontaneous  Evolution  .         .         .         .         .     .  672 

332.  Termination  of  Spontaneous  Evolution        ...                  .         .  672 

333.  Spontaneous  Expulsion  ..........  673 

334.  Decapitating  Hook,  with  serrated  edge       .         .         .         .  •       .         .  674 

335.  Decapitation 674 

336.  Presentation  of  Head  and  Hand          .......  677 

337.  Dorsal  Displacement  of  Arm  .........  678 

338.  Presentation  of  a  Hand  and  Foot  with  Funis      .....  679 

339.  Locked  Twins 680 

340.  Thoracopagus  Monster 684 

341.  Dicephalus  Monster 684 

342.  Syncephalus  Monster 685 

343.  Anencephalus  Monster   ..........  685 

344.  Labour  impeded  by  Hydrocejahalus     .......  690 

345.  Encephalocele         ...........  693 

346.  Pelvimeter 701 

347.  Measurement  of  Diagonal  Conjugate      .......  705 

348.  Diagram  for  Calculation  of  True  Conjugate        .....  707 

349.  Sagittal  Section  of  a  Normal  Pelvis         .......  712 

350.  Sagittal  Section  of  a  Small  Round  Pelvis    ......  712 

351.  Infantile  Pelvis 713 

352.  Section  of  a  Normal  Pelvis  parallel  to  and  just  below  the  Inlet .         .  716 

353.  Section  of  Flattened  Rachitic  Pelvis  parallel  to  and  just  below  the 

Inlet 717 

354.  Sagittal  Section  of  a  Rickety  Flat  Pelvis     ......  717 

355.  Upper  half  of  a  Section  through  a  Normal  and  Rachitic  Innominate 

Bone     .         .         • 718 

356.  Reniform  Rachitic  Pelvis     .........  719 

357.  Skeleton  of  Rachitic  Dwarf  with  Contracted  Pelvis         .         .         .     .  720 

358.  The  Outlet  of  a  Rickety  Flat  Pelvis 721 

359.  Median  Section  through  a  Flat  Rachitic  Pelvis 722 

360.  Median  Section  through  a  Flat  Rachitic  Pelvis  with  marked  Bending 

of  the  Sacrum 723 

361.  Figure-of-eight  Rachitic  Pelvis       ........  724 

362.  Chondrodystrophic  Pelvis    .........  725 

363.  Engagement  of  Head  in  Brim  of  flattened  Pelvis,  viewed  from  below 

in  the  Axis  of  the  Brim 726 

364.  The  Rhomboid  of  Michaelis  in  a  Woman  with  a  well-formed  Pelvis  .  733 

365.  Pregnancy  with  Double  Congenital  Dislocation  of  the  Hij)S  .         .     .  735 

366.  Transverse  Section  of  Fcjetal  Skull 743 


xxviii  List  of  Illustrations. 

FIGURE  PAGE 

367.  Transverse  Section  of  Foetal  Skull,  showing  the  Alterations  produced 

by  Yertical  Compression       .........  744 

368.  Transverse  Section  of  Foetal  Skull,  showing  the  Outline  of  Skull  as 

compressed  by  Extraction  after  Version  ......  744 

369.  Passage  of  After-coming  Head  through  Eeniform  Flattened  Pelvis    .  744 

370.  Munro   Kerr's  Method  of  determining  the  Eelative  Size  of  Foetal 

Head  and  Pelvis 758 

371.  Triradiate  Malacosteon  Pelvis  in  Extreme  Deformity,  viewed  in  the 

Axis  of  the  Brim  ...........  763 

372.  The  same  Malacosteon  Pelvis,  seen  from  the  Outlet    ....  764 

373.  Eostrated  Malacosteon  Pelvis,  in  Earlier  Stage  of  Deformity          .     .  765 

374.  Eostrated  Malacosteon  Pelvis,  seen  from  the  Outlet  ....  766 

375.  Pseudo-malacosteon  Eachitic  Pelvis 767 

376.  The  Outline  of  the  Pelvic  Brim  in  the  principal  varieties  of  Con- 

tracted Pelvis    ...........  768 

377.  Scoliotic  Flattened  Pelvis 770 

378.  Oblique  Pelvis,  from  Anchylosis  of  the  Hip-joint,  and  Disuse  of  Eight 

Leg  .         .         .         .         .         .         .         .         .         .         .         .         .771 

379.  Oblique  Pelvis  of  Naegele 772 

380.  An  Oblique  Pelvis  of  Naegele,  in  which  the  Distortion  is  only  slight .  773 

381.  Oblique  Pelvis  of  Naegele  seen  from  behind  .         .         .         .         .     .  774 

382.  Transversely  contracted  Pelvis  of  Eobert 777 

383.  Figure  of  Woman  with  Kyphotic  Pelvis          .         .         .         .         .     .  779 

384.  Kyphotic  Pelvis 780 

385.  Pelvis  of  a  Woman  who  had  been  bedridden  from  Infancy  iip  to  the 

Age  of  31 784 

386.  Figure  of  Woman  with  Spondylolisthetic  Pelvis          ....  785 

387.  Spondylolisthetic  Pelvis .         ." 786 

388.  Bony  Growth  of  the  Sacrum        ........  787 

389.  Sacral  Exostosis  filling  the  Pelvis 788 

390.  Minor  Degree   of   Deformity  from   Exostosis  of   the  Cristie  of  the 

Pubes        ............  788 

391.  Cancerous  Growths  from  the  Bones  of  the  Pelvis,  causing  Deformity.  789 

392.  Enchondroma  of  Sacrum  obstructing  Labour      .....  790 

393.  Horrocks'  Maieutic 797 

394.  Maieutic,  fixed  on  Catheter         . 797 

395.  Maieutic,  distended  i)i  situ 798 

396.  Hearson's  Thermostatic  Nurse 802 

397.  Pinard's  Manoeuvre         ..........  810 

398.  The  Blunt  Hook 812 

399.  Axis-traction  Forceps  applied  to  the  Breech  .         .         .         .         .     .  814 

400.  The  Manner  in  which  the  Pelvis  of  the  Child  should  be  grasped  by 

the  two  Hands  ...........  814 

401.  Bringing  down  extended  anterior  Arm 816 

402.  Shoulder  and  Jaw  Traction 818 

403.  The  Vectis 821 

404.  Short  straight  Forceps 824 

405.  Short  cruwed  Forceps,  with  French  Lock 824 

406.  Long  straight  Forceps 825 

407.  Diagram  illustrating  the  Defects  of  long  straight  Forceps      .         .     .  826 


List  of  Illustrations.  xxix 

FIGURE  PAGE 

408.  Simpson's  Forceps 828 

409.  Barnes'  Forceps 828 

410.  Long  ciirved  Forceps  . 830 

411.  Tarcier's  Axis-traction  Forceps,  withi  tlie  Traction-handle  removed  .  832 

412.  Upper  or  right-hand   Blade   of    Tarnier's    Axis-traction    Forceps . 

Traction  Eod  detached  for  cleansing  of  Hinge         ....  833 

413.  Traction  with  Tarnier's  Axis-traction  Forceps 833 

414.  Axis-traction  Forceps 834 

415.  Axis-traction  Forceps  with  Screw  at  end  of  Handles      .         .         .     .  835 

416.  Diagram    showing    the  Increase    in   the    Conjugate   Diameter    in 

Walcher's  position 838 

417.  Introduction  of  first  or  lower  Blade  of  Axis-traction  Forceps         .     .  841 

418.  Introduction  of  second  or  upper  Blade  of  Axis-traction  Forceps         .  842 

419.  Diagram  to  illustrate  Introduction  of  second  or  upper  Blade  of  long 

curved  Forceps         ..........  844 

420.  Mode  of  making  Axis-traction  with  ordinary  long  curved  Forceps     .  848 

421.  Mode  of  delivering  Head  through  Vulval  Outlet 851 

422.  Tarnier's  Axis-Traction  Forceps 855 

423.  The  Author's  Axis-traction  Foi'ceps        .......  856 

424.  External  Cephalic  Version  with  the  Woman  in  the  Trendelenburg 

position    ............  862 

425.  First  Stage  of  Bipolar  Version 866 

426.  Second  part  of  Fii'st  Stage  of  Bipolar  Version     .....  867 

427.  Second  part  of  First  Stage  of  Bipolar  Version,  when  Head  becomes 

extended 868 

428.  Second  Stage  of  Bipolar  Version          .......  869 

429.  Commencement  of  Third  Stage  of  Bipolar  Version          .         .         .     .  869 

430.  Second  part  of  Third  Stage  of  Bij)olar  Version    .....  870 

431.  Internal  Version  in  Head  Presentation  .......  872 

432.  Internal  Version  in  Head  Presentation.     Seizing  the  Leg  .         .         .  874 

433.  Version  by  Leg  diagonally  opposite  to  presenting  Shoulder   .         .     .  876 

434.  Internal  Version  in  Transverse  Presentation,  dorso-anterior  position  877 

435.  Internal  Version  in  Transverse  Presentation.    Seizing  the  lower  Foot .  878 

436.  Version  by  the  nearer  Leg,  or  that  corresponding  to  the  presenting 

Shoulder.     Noose  placed  upon  prolapsed  Arm         ....  879 

437.  Internal  Version.     Leg  drawn  down  into  Vagina,  Head  pushed  up  to 

Fundus 880 

438.  Oldham's  Perforator 884 

439.  Simpson's  Perforator 884 

440.  Perforation  of  Head 886 

441.  Craniotomy  Forceps  with  Screw  to  Handles 888 

442.  Eoper's  Craniotomy  Forceps        .         .         .    - 889 

443.  Elongation  of  Head  in  Conical  Form  by  Extraction  with  Craniotomy 

Forceps 890 

444.  Braxton  Hicks'  Cephalotribe 892 

445.  Head  crushed  by  Cephalotribe •         .     .  894 

446.  Simpson's  Splitting  Basilyst 896 

.447.  Auvard's  three-bladed  Cephalotribe 896 

448.  Craniotomy  Forceps    ..........  898 

449.  Crochet 900 


XXX  List  of  Illustrations. 

FIGURE  PAGE 

450.  Diagram  of  Mode  of  applying  Sutures  in  Sanger's  Operation     .         .  909 

451.  Diagram  of  Sutures  secured  in  Sanger's  Oj^eration         .         .         .     .  910 

452.  Application  of  Sutures  in  Csesarean  Section        .....  910 

453.  Sutui'es  tied  according  to  Sanger's  Method,  seen  from  above          .     .  911 

454.  Author's  Method  of  placing  Sutures  to  unite  Abdominal  Wall   .         .  912 

455.  Koeberle's  Serre-noeud 917 

456.  Guarded  Pin  for  fixing  Stump  of  Uterus  in  Abdominal  Wound          .  917 

457.  Vaginal  Csesarean  Section       .         .         .         .         .         .         .         .     .  921 

458.  Separation  of  Pubic  Bones  in  Symphysiotomy    .....  924 

459.  Symphysiotomy  Knife    ..........  927 

460.  Pinard's  Eegistering  Separator  for  Symphysiotomy    ....  928 

461 .  Bumm's  Subcutaneous  Method  of  performing  Pubiotomy      .         .     .  930 

462.  Gigli's  Saw  in  position  for  sawing  through  the  Bones          .         .         .  932 

463.  Over-distension  of  the    lower  Uterine  Segment  in  Transverse  Pre- 

sentations   ............  935 

464.  Eupture  of  Cervix  and  lower  Uterine  Segment   .....  937 

465.  Eupture  of  Cervix,  lower  Uterine  Segment,  and  posterior  Vaginal 

Fornix 939 

466.  Eupture   of  the   lower  Uterine  Segment   with   large  subperitoneal 

Hcematoma      ...........  940 

467.  Incomplete  Eupture  of  Perineum  .         .         .         .         .         .         .     .  951 

468.  Complete  Eupture  of  Perineum  into  Eectum       .....  951 

469.  Antero-posterior  Section  of  Perineal  Body  in  I'rimiioaras        .         .     .  952 

470.  Hagedorn's  Needles 955 

471.  Hagedorn's  Needle-holder 955 

472.  Prolapse  of  Funis,  with  the  Head  in  the  first  position         .         .         .  960 

473.  Gum-elastic  Catheter,  adapted  as  Funis  Eepositoi' 963 

474.  Commencing  Inversion  of  the  Uterus          ......  965 

475.  Complete   Inversion  of  Uterus   with   Prolapse.     The  Placenta  still 

attached 966 

476.  Sagittal  Section  of  Pelvis  with  complete  Inversion  of  Uterus      .         .  967 

477.  Modified  Aveling's  Eepositor  for  Inversion  of  Uterus     .         .         .     .  970 

478.  Modified  Aveling's   Eepositor  applied    for   Eeduction    of  inverted 

Uterus 971 

479.  Uterus  with  adherent  Cotyledon  of  Placenta  from  Patient  dj'iug  of 

ante-partum  and  post-partum  Haemorrhage 974 

480.  Eetained  Placenta  from  Hour-glass  Contraction  of  the  Uterus  .         .  976 

481.  Eemoval  of  an  adherent  Placenta  ........  977 

482.  Uterus  and  Vagina  properly  and  comj^letely  plugged  with  Gauze      .  986 

483.  Uterus  and  Vagina  improperly  plugged  with  Gauze       .         .         .     .  987 

484.  Horrocks'  Apparatus  for  Intra-venous  Injection         ....  989 

485.  Diagram  of  Annual  Variation  of  Puerperal  Fever  and  other  Diseases 

for  London 1000 

486.  Uterus  showing  Acute  Sloughing  Endometritis 1006 

487.  Uterus    from    a    Case    of    Acute    Septicaemia    following    criminal 

Abortion,  ending  fatally  on  the  Sixth  Day 1008 

488.  Diagram  illustrating  Spread  of  Infection  from  the  Cervix  and  the 

Uterus 1010 

489.  Diagam  illustrating  the  Spread  of  a  Septic  Thrombo  Phlebitis       .     .  1011 

490.  Temperature  Chart  of  a  Case  of  Acute  Septicaemia      ....  1014 


List  of  Illustrations.  xxxi 

FIGURE  PAGE 

491.  Temperature  Chart  of  a  Case  of  Sapraemia,  due  to  retained  Membranes  1019 

492.  Diagram  of  Situation  of  Thickening  in  Parametritis       .         .         .     .  1024 

493.  Diagram  of  Annual  Variation  of  Pvierperal  Fever  and  other  Diseases 

for  England  and  Wales 1025 

494.  Uterus  with  a  portion  of  retained  Placenta  from  a  Patient  dying  of 

Septicaemia        .         .         .         .         .         .         .         .         .         .         .  1035 

495.  Ohorionepithelioma  of  Uterus  with  Lutein  Cysts  in  both  Ovaries  .     .  1061 

496.  Microscopic  Section  of  Ohorionepithelioma  .....  1063 

497.  A  Collection  of  Epithelial  Cells  lying  within  a  Bloodvessel  from  a 

Case  of  Hydatidiform  Mole 1064 

498.  Chorionepithelioma  of  Uterus  with  Secondary  Growths  in  Vagina  and 

in  Perivaginal  Connective  Tissue      .......  1067 

499.  Spoon-shaped  Depression  on  Foetal  Skull       .         .         .         .         .     .  1081 

500.  L-shaped  Depression  on  Foetal  Skull 1081 

501.  Fracture  of  Parietal  Bone  in  Case  of  Forceps  Delivery  .         .         .     .  1082 

502.  Schultze's  Method.     Position  of  Expiration 1092 

503.  Schultze's  Method.     Position  of  Inspiration  .         .         .         .         .     .  1092 


THE 

Practice  of  Midwifery 


Chapter  I. 

ANATOMY    OF    THE    PELVIS 

The  study  of  the  anatomy  of  the  pelvis  is  of  primary  importance 
for  the  obstetric  art,  since  upon  the  disproportion  of  its  size  to  that 
of  the  foetus,  or  abnormaHty  of  its  shape,  depends  a  large  propor- 
tion of  the  difficulties  which  are  met  with  in  delivery.  The  pelvis 
is  a  structure  adapted  for  fulfilling  many  functions  at  once,  and  its 
obstetric  functions  are  greatly  influenced  by  the  purely  mechanical 
conditions  to  which  it  is  subjected.  It  forms  (1)  a  bony  ring,  by 
means  of  which  the  weight  of  the  body  is  transmitted  to  the  legs ; 
(2)  an  axis  for  the  movements  of  the  legs  upon  the  trunk  ;  (3)  an 
attachment  for  many  of  the  most  powerful  muscles  of  the  trunk 
and  of  the  legs  ;  (4)  a  cavity  to  contain  the  pelvic  viscera ;  and 
(5)  a  bony  canal  for  the  passage  of  the  child  in  parturition.  The 
rough  external  surface,  with  many  prominences  to  afford  leverage, 
is  adapted  for  the  attachment  of  muscles ;  the  smooth  internal 
surface  is  suitable  for  the  passage  of  the  foetus.  Owing  to  the 
erect  posture  of  women,  the  contents  of  the  abdomen  and  pelvis 
tend  to  gravitate  towards  the  pelvic  outlet.  Hence  there  is  a 
mechanical  difficulty,  which  does  not  exist  in  the  case  of  animals, 
in  rendering  the  structures  which  close  the  pelvis  strong  enough 
to  prevent  any  undue  yielding  under  pressure.  There  are  two 
peculiarities  in  the  formation  of  the  bony  pelvis  which  tend  to 
diminish  tbis  difficulty.  First,  the  considerable  inclination  which 
the  brim  of  the  pelvis  has  to  the  horizon  in  the  standing  position 
has  the  effect  that  the  major  portion  of  the  weight  of  the  abdominal 
and  pelvic  viscera  rests  rather  upon  the  anterior  abdominal  wall 
and  anterior  bony  wall  of  the  pelvis,  than  upon  the  soft  parts 
which  close  the  pelvis  inferiorly.     Secondly,  owing  to  the  curvature 

M.  1 


2  The  Practice  of   Midwifery. 

of  the  pelvic  canal,  greater  than  that  of  the  pelvis  of  animals,  the 
lower  part  of  the  sacrum  and  coccyx  afford  some  measure  of  bony 


Fig.  1. — Os  innominatum. 


support  to  the  contained  viscera,  and  give  a  firm  attachment  to  the 
muscles  and  other  structures  which  constitute  the  pelvic  floor. 
As  in  almost  all  mammalia,  the  pelvis  is  made  up  of  four  bones  : 

two  ossa  innominata,  the 
sacrum  and  the  coccyx.  Of 
these,  each  os  innominatum 
is  formed  by  the  union  of 
three  principal  portions,  the 
ilium,  ischium,  and  puhes. 
These  are  separated  from 
each  other,  generally  up  to 
about  the  age  of  twenty,  by 
a  triradiate  or  Y-shaped  piece 
of  cartilage,  having  its  centre 
at  the  acetabulum.  In 
addition  to  the  pelvis  proper, 
the  last  lumbar  vertebra  has 
also  to  be  taken  into  con- 
sideration in  relation  to 
certain  pelvic  deformities. 
The  student  will  be  assumed 
to  be  fully  acquainted  with  these  bones,  as  described  in  text-books 
of  anatomy,  and  those  points  only  which  have  a  special  bearing 
on  obstetrics  will  be  here  considered. 


Fig.    2. 


-  Division    between    the 
ischium,  and  pubes. 


ilium, 


Anatomy  of  the  Pelvis.  3 

The  Pelvis  as  a  whole. — The  formation  of  the  pelvis  out  of 
several  bones,  instead  of  as  a  completely  ossified  ring,  serves  a 
triple  purpose.     1st.  It  allows  the  progressive  development  which 


Fig.  3. — Sacrum  and  coccyx. 


Fig.  i. — Section  of  sacrum 
and  coccyx. 


takes  place  especially  about  the  age  of  puberty  in  the  female  sex. 
2nd.  By  allowing  a  certain  degree  of  yielding  of  the  joints,  it 
diminishes  the  risk  of  fracture.     3rd.  It  diminishes  in  some  degree 


Fig.  5. — Female  pelvis,  seen  from  the  front. 

the  jar  transmitted  to  the  trunk  and  brain  from  any  concussion 
upon  the  feet. 

The  pelvis  is  divided  into  two  parts  by  an  irregularly  oval  ring, 
somewhat  approximating  towards  a  heart-shape,  which  constitutes 
the  pelvic  Jjiiin  or  inlet  and  is  the  part  of  the  bony  canal  at  which 

1—2 


4  The  Practice  of   Midwifery. 

deformities  most  frequently  exist,  and  impediment  to  the  passage 
of  the  foetus  most  frequently  occurs.  The  upper  half,  or  false 
pelvis,  has  no  direct  concern  with  the  mechanism  of  parturition, 


Fig.  6. — Female  pelvis,  viewed  in  the  axis  of  the  brim.  Antero-posterior 
or  conjugate,  transverse,  and  oblique  diameters  marked,  with  measure- 
ments in  inches  and  centimetres. 


and  chiefl}^  interests  the  obstetrician  by  the  fact  that,  from 
varieties  in  its  measurements,  inferences  may  be  drawn  as  to  the 
condition  of  the  true  pelvis.  The  lower  half,  or  true  pelvis,  includes 
the  brim  itself  and  all  the  structures  below  it.    The  parts  requiring 


Fig.  7.— Outlet  of   pelvis.      Antero-posterior    and    transverse  diameters 
marked,  with  measurements  in  inches  and  centimetres. 

separate  consideration  are  the  hrim  or  inlet,  the  outlet,  and  the 
cavity,  or  space  comprised  between  inlet  and  outlet.  The  brnn  is 
formed  by  the  upper  margin  of  the  pubes  in  front,  the  ilio-pectineal 
line  of  the  innominate  bone  on  either  side,  and  the  upper  ^  and 
anterior  margin  and  promontory  of  the  sacrum  behind.    It  is  to 


Anatomy  of  the  Pelvis.  5 

be  noted,  however,  that,  although  the  promontory  of  the  sacrum  is 
usually  regarded  as  formmg  part  of  the  brim,  it  generally,  in  the 
normal  pelvis,  lies  slightly  above  the  true  plane  of  the  brim. 
Thus  the  plane  of  the  brim  cuts  the  front  of  the  sacrum  in  a  line 
situated  at  a  small  but  variable  distance  below  the  promontory ; 
and,  if  the  promontory  of  the  sacrum  is  regarded  as  forming  part 
of  the  curve  of  the  brim,  that  curve  does  not  lie  accurately  in  one 
plane.  The  promontory  of  the  sacrum  forms  a  flattened  portion 
in  the  curve  of  the  brim  even  in  the  normal  pelvis,  but  does  not 
actually  project  inwards.  In  the  commoner  varieties  of  deformity, 
it  does  so  project  inwards,  and  causes  the  shape  of  the  brim  to 
resemble  an  actual  heart-shape  or  kidney-shape.  The  cavity  of 
the  pelvis  is  bounded  by  the  sacrum  and  coccyx  behind,  the  pubic 
bones  in  front,  the  inner  surface  of  the  innominate  bones,  with  the 
sacro-sciatic  ligaments  and  the  muscles  attached  to  them,  at  the 
sides.  The  outlet  is  lozenge-shaped,  and  has  the  tubera  ischii  at 
each  side,  the  rami  of  the  ischia  and  pubes  converging  to  the  lower 
margin  of  the  symphysis  pubis  in  front,  and  the  sacro-sciatic 
ligaments  converging  to  the  coccyx  and  lower  end  of  sacrum 
behind.  The  pelvic  brim  is  sometimes  termed  the  superior  strait, 
the  outlet  the  inferior  strait. 

Differences  between  Male  and  Female  Pelvis. — There  are 
important  differences  between  the  male  and  female  pelvis,  the 
peculiarities  of  the  latter  being  necessary  to  qualify  it  for  its 
functions  in  parturition.  The  bones  of  the  female  pelvis  are 
thinner  and  slighter,  and  the  prominences  for  muscular  attach- 
ment less  strongly  marked.  When  looked  at  from  the  front,  the 
female  pelvis  is  seen  to  be  shallower,  wider,  and  less  funnel-shaped, 
the  outlet  being  relatively  larger  in  proportion  to  the  inlet.  Koughly 
speaking,  the  female  pelvis  forms  a  short  segment  of  a  long  cone, 
while  the  male  pelvis  is  a  long  segment  of  a  short  cone.  As  a 
consequence,  both  the  tubera  ischii  and  the  acetabula  are  much 
farther  apart  in  the  former.  The  latter  circumstance  causes 
woman  to  have  a  more  undulatory  or  side-to-side  movement  in 
walking  than  man.  The  iliac  fossae  are  inclined  at  about  the  same 
angle  to  the  axis  of  the  brim  in  the  two  sexes ;  but,  in  consequence 
of  the  greater  width  of  the  true  pelvis,  the  iliac  crests  are  farther 
apart  in  woman,  and  thus  give  the  greater  breadth  across  the  hips 
to  woman's  figure.  The  iliac  crests  are  also  more  curved,  and, 
in  consequence,  the  iliac  fossae  more  hollowed  out.  A  marked 
difference  is  the  greater  width  of  the  pubic  arch,  which  in  woman 
is  usually  greater  than  a  right  angle,  on  the  average  about  96° ; 


6  The  Practice  of   Midwifery. 

in  man  less  than  a  right  angle,  on  the  average  ahout  75°.  The 
depth  of  the  symphysis  pubis  is  much  less  in  woman,  and  the 
sacrum  is  broader.     The  obturator  foramina  are  more  triangular, 


Fig.  8. — Male  pelvis,  seen  from  the  front. 

and  their  vertical  diameter  less  in  proportion.  The  great  sacro- 
sciatic  notch  is  shallower  and  wider.  The  dimensions  of  the  brim 
are  manifestly  larger,  and  more  especially  the  magnitude  of  the 
transverse  in  proportion  to  the  antero-posterior  diameter.  Verneau 
gives  for  adult  females  the  following  averages :  transverse  13"5  cm.. 


Fig.  9. — Male  pelvis,  viewed  in  the  axis  of  the  brim. 


conjugate  10'6  ;  males  :  transverse  13*0  cm.,  conjugate  10*4.  The 
shape  of  the  brim  also  differs  somewhat,  the  male  brim  approxi- 
mating more  to  a  cordate,  the  female  to  an  oval  shape.  This 
difference  is  due  to  the  maximum  transverse  diameter  in  the  male 
being  placed  more  posterior  to  the  centre  of  the  brim  than  the 


Anatomy  of  the  Pelvis. 


7 


maximum  transverse  diameter  in  the  female.  Looked  at  from 
below,  the  greater  size  of  the  outlet  of  the  female  pelvis  is  still 
more  manifest  than  that  of  the  inlet. 

These  peculiarities  in  the  female  pelvis  are  connected  with  the 
presence  in  it  of  the  female  genital  organs,  and  the  larger  space 
which  they  occuj)y.  In  cases  in  which  the  uterus  and  ovaries  are 
imperfectly  developed,  the  pelvis  is  not  infrequently  small,  and 
conversely,  in  cases  of  double  uterus,  the  transverse  diameter  of 
the  pelvis  has  been  found  unusually  large.  There  is  considerable 
variety  in  different  individuals  in  the  degree  in  whioh  the 
characteristics  of  the  female  pelvis,  especially  the  large  size  of 
the  brim,  associated  with  great  length 
of  the  transverse  compared  to  the 
antero-posterior  diameter,  are 
developed. 

In  some  women,  in  whom  the 
pelvis  resembles  the  male  type,  con- 
siderable difficulty  may  be  experienced 
in  child-birth.  There  are  also  differ- 
ences between  different  races.  In  the 
most  intellectual  races  the  pelvis  is 
most  fully  developed  in  area,  a  differ- 
ence which  must  be  associated  with 
the  greater  size  of  the  children's 
heads.  The  development  is  greatest 
in  the  Circassian  race,  and  affects 
especially  the  transverse  diameter. 
In  the  more  savage  races,  on  the 
contrary,  such  as  Negroes,  Hottentots, 
Bushmen,  and  Australian  Aborigines, 
not  only  is  the  size  somewhat   less, 

but  the  pelvic  brim  is  more  round,  from  relative  smallness  of 
the  transverse  diameter,  and  thus  shows  a  slightly  greater  resem- 
blance to  the  type  of  the  monkey's  pelvis,  in  which  the  antero- 
posterior diameter  is  greater  than  the  transverse  (see  Fig.  10). 
The  angle  of  the  pubic  arch  is  also  generally  not  so  great. 
Difficulties  in  parturition,  however,  more  often  occur  in  the 
higher  races,  since  the  greater  size  of  the  pelvis  is  more  than 
compensated  by  the  greater  size  and  less  compressibility  of  the 
fcetal  head. 

Thus  liiggs  has  shown  that  while  contracted  pelves  occur  in 
34  per  cent,  of  the  black  women  as  compared  with  9  per  cent,  of 
the  white  women  in  Baltimore,  owing  to   the  smaller  and  more 


Fig.  10. — Pelvis  of  chimpanzee. 


8 


The  Practice  of   Midwifery. 


compressible  heads  of  the  negro  children,  artificial  delivery  is  more 
often  required  among  the  latter.^ 

Inclination  of  the  Pelvis.— It  was  formerly  supposed  that,  in 
the  erect  position,  the  plane  of  the  pelvic  brim  was  only  slightly 
inclined  to  the  horizon,  that  is,  that  it  was  nearly  in  the  position 
which  it  assumes  when  the  dry  pelvis  is  placed  upon  a  table, 


Fig.  1 1 . — Antero-posterior  section  of  pelvis.  /<j;,  horizoutal  plane ;  axjyh,  axis 
of  pelvic  brim  ;  r  I.  vertical  line  of  body  ;  c  i;  conjugata  vera  ;  |;  ss,  plane 
of  superior  strait ;  ^;  gd,  plane  of  greatest  dimensions  ;  ^  Id,  plane  of 
least  dimensions  ;  jj  ]}  o,  plane  of  pelvic  outlet  ;  m  p^,  median  plane  ; 
in  c  c,  Meyer's  normal  conjugate.     (After  Bayer.^) 

resting  upon  the  tip  of  the  coccyx  and  the  tubera  ischii.  A  trace 
of  this  error  still  remains  in  the  term  horizontal  ramus,  applied  to 
the  upper  ramus  of  the  pubes,  whereas  in  the  upright  position  of 
the  man  or  woman  this  ramus  is  in  reality  more  nearly  vertical 
than  horizontal.  It  was  first  shown  by  Naegele  that  the  plane  of 
the  brim,  in  the  erect  position,  approaches  more  nearly  to  the 
vertical   than    the  horizontal,  and  he  estimated  the  angle  which 

1  Eiggs,  J.  F.,  .Johns  Hopkins  Hospital  Eeports,  1904,  Vol.  XII.,  p.  421. 

2  Bayer,  Vorlesungen  iiber  AUgemeine  Geburtshiilfe,  1903,  Bd.  1,  Heft  2,  p.  137. 


Anatomy  of  the  Pelvis.  9 

it  makes  with  the  horizon  at  60°  or  more.  According  to  the 
observations  of  Meyer,  it  varies,  according  to  the  position  of  the 
thighs,  from  45°  to  100°,  and  in  the  usual  erect  posture,  is  on  an 
average  55°. 

In  view  of  the  variations  in  the  inclination  of  the  pelvis  in 
different  positions  of  the  body,  Meyer  has  proposed  to  term  the 
normal  conjugate  a  plane  passing  through  the  upper  border  of 
the  symphysis  pubis  and  the  centre  of  the  body  of  the  third  sacral 
vertebra,  since  this  portion  of  the  sacrum  moves  least  in  any 
alteration  of  the  jDOsition  of  the  trunk  or  of  the  lower  limbs  ^ 
(Fig.  11).  Taking  the  angle  of  pelvic  inclination  at  60°,  it  follows 
that  the  height  of  the  promontory  of  the  sacrum  above  the  top  of 
the  pubes  is,  on  the  average,  about  3f  inches.  A  line  passing 
horizontally  backwards  through  the  top  of  the  pubes  passes  below 
the  tip  of  the  sacrum,  and  intersects  the  coccyx.  The  tip  of  the 
coccyx  is  above  the  level  of  the  ajDex  of  the  pubic  arch,  and  a  line 
joining  these  two  points  makes  an  angle  of  about  10°  with  the  horizon. 

In  the  upright  position  the  vertical  line  through  the  centre  of 
gravity  of  the  body  passes  through  a  point  a  little  behind  the 
promontory  of  the  sacrum.  It  corresponds  with  the  line  v  l  in 
Fig.  11.  For  equilibrium  to  be  maintained,  when  the  body  is 
balanced  upon  the  heads  of  the  femora  by  the  aid  of  gentle 
muscular  action,  this  vertical  line  must  lie  exactly,  or  almost 
exactly,  in  the  vertical  plane  through  the  points  where  the 
acetabula  rest  upon  the  heads  of  the  femora.  In  standing  at  ease, 
however,  the  inclination  of  the  pelvis  is  slightly  diminished,  until 
the  strong  ilio-femoral  ligaments,  or  one  of  them,  are  put  upon  the 
stretch,  and  relieve  the  muscles  in  the  duty  of  maintaining  the 
balance.  The  vertical  line  through  the  centre  of  gravity  then 
falls  somewhat  behind  the  vertical  plane  passing  through  the 
acetabula. 

In  pregnancy,  or  when  any  abdominal  tumour  exists,  the  pelvic 
inclination  is  diminished.  The  centre  of  gravity  of  the  body  in  its 
new  position  must  be  brought  over  the  points  of  support  at  the 
heads  of  the  femora,  in  order  to  maintain  the  balance.  This  is 
effected  partly,  it  is  true,  by  the  woman  throwing  her  shoulders 
backward,  and  so  altering  the  curve  of  the  spine,  but  partly  also 
l)y  rotation  backward  of  the  whole  trunk  together  upon  the  heads 
of  the  femora.  The  effect  which  such  rotation  through  any  given 
angle  will  have  upon  the  position  of  the  centre  of  gravity  will  be 
greater  in  proportion  to  the  height  of  a  woman.  Hence,  in  short 
women,  during   pregnancy,  either   the   inclination   of  the   pelvis 

'  H.  Meyer,  Stutik  und  Mechanik  <ler  Menschliclieri  Kiiocliengeriistes,  1873. 


lO 


The  Practice  of   Midwifery. 


is  more  diminished  than  in  tall  women,  or,  more  frequently,  the 
shoulders  are  more  thrown  back,  and  thus  the  i^regnant  condition 
becomes  more  manifest. 


Articulations  of  the  Pelvis. — There  are  certain  peculiarities 
about  the  pelvic  articulations  which  adapt  them  for  the  functions 
of  parturition,  and  accordingly  there  is  a  slight  difference  between 
the  male  and  female  pelvis  as  regards  these  joints. 

Sar.ro-iliac  Articulation. — This  is  formed  between  the  auricular 
surfaces  of  the  sacrum  and  ilia,  which  are  each  covered  by  a  layer 
of   cartilage,  and   are   closely   applied   together,  but   not   usually 

directly  united.  At  times  the  two 
surfaces  are  connected  by  firm 
transverse  fibres,  but  in  the  adult 
woman,  and  especially  in  preg- 
nancy, spaces  containing  serous 
fluid  exist  between  them,  and  a 
certain  small  degree  of  movement 
is  permitted.  The  nature  of  this 
movement  is  a  tilting  of  the  sacrum 
backward  or  forward  relatively  to 
the  pelvis  upon  a  transverse  axis 
passing  through  the  centre  of 
the  joint.  Thus,  by  the  tilting 
backwards  of  the  promontory  of 
the  sacrum  the  antero-posterior 
diameter  of  the  inlet  is  somewhat 
increased,  and  at  the  same  time 
the  anterior  wider  part  of  the 
auricular  surface  of  the  sacrum 
being  pressed  backwards  between 
the  two  ilia  separates  them  to  a  greater  degree,  and  so  further 
increases  the  dimensions  of  the  pelvic  inlet,  while  conversely  by 
the  tilting  backward  of  the  lower  extremity  of  the  sacrum  there  is 
a  slight  gain  of  space  at  the  outlet  (see  Fig.  12). 

The  centre  of  movement  is  nearer  to  the  promontory  than  to  the 
tip  of  the  sacrum.  Hence  the  tip  describes  an  arc  of  a  longer  circle 
than  the  promontory,  and  the  diameter  of  the  outlet  is  more  affected 
than  that  of  the  inlet.  It  is  estimated  by  Matthews  Duncan  that, 
by  nutation  forward  of  the  promontory,  the  conjugate  diameter  of 
the  inlet  may  be  diminished  as  much  as  one  or  even  two  lines,  and 
that  to  this  diminution  corresponds  an  augmentation  of  the  corre- 
sponding diameter  of  the  outlet  of  probably  double  the  amount. 


Fig.  12. — Nutation  of  sacrum  during 
parturition. 

a  h.  Symphysis  pubis. 

c  d.  Ordinary  position  of  sacrum. 

o"  d".  Sacrum  in  its  position  of 
extreme  nutation.  The  tip 
of  the  sacrum  is  carried  back- 
ward, so  as  to  augment  the 
antero-posterior  diameter  of 
tiie  inferior  strait. 

(After  Matthews  Duncan.) 


Anatomy  of  the  Pelvis. 


1 1 


In  this  way  parturition  is  facilitated  in  a  perceptible  degree.  At 
the  early  stage  of  labour  the  woman  is  naturally  inclined  to  be  up 
and  about,  or,  if  in  bed,  to  lie  with  the  thighs  extended  ;  and  in 
these  positions  the  promontory  of  the  sacrum  is  tilted  back,  and 
the  pelvic  brim  gains  its  greatest  dimensions.  When,  however, 
the  head  is  passing  through  the  outlet,  she  instinctively  draws  up 
her  knees  and  bends  her  body  over  them,  while  the  contraction  of 
the  abdominal  muscles  draws  the  pubes  upward.  The  effect  of 
this  is  to  tilt  the  promontory  forward  and  the  lower  end  of  the 
sacrum  with  the  coccyx  backward,  and  so  give  increased  room  at 
the  outlet.      A  similar  movement  has  been  described  as  taking 


Fig.  13. — Antero-posterior  section  of  sacrum  and  symphysis  pubis  to  show 
the  increase  in  the  conjugate  diameter  ;  in  the  horizontal  position  11 -5  cm. , 
in  Walcher's  position  ITS  cm.,  as  compared  with  10'9  cm.  in  the  lithotomy 
position.      (After  Klittner.) 


place,  in  lesser  degree,  by  the  assumption  of  a  similar  position 
in  defecation.  A  still  greater  nutation  of  the  i^romontory  of  the 
sacrum  backward  and  increase  of  the  conjugate  diameter  than 
that  which  occurs  in  the  horizontal  position  is  produced  by  the 
Walcher  position,  in  which  the  woman  lies  on  her  back,  with  her 
buttocks  resting  on  the  edge  of  the  table,  and  her  legs  hang  down 
vertically  without  any  support.  According  to  Kiittner  ^  the  con- 
jugate is  increased  by  the  horizontal  position  "6  cm.,  and  by  the 
Walcher  position  '9  cm.  (about  -^  inch),  as  compared  with  the 
lithotomy  position  (Fig.  13).  With  these  increases  correspond 
diminutions  of  1"3  and  1-8  cm.  respectively  in  the  antero-posterior 
diameter  of  the  outlet  (Fig.  14). 

1  Kuttner,  Hegar's  Beitrage,  1898,  Vol.  I.,  p.  211. 


12 


The  Practice  of   Midwifery. 


In  consequence  of  this,  advantage  is  taken  of  the  Walcher  position 
to  facihtate  the  passage  of  the  head  through  the  brim  in  cases 
of  contraction  of  the  conjugate  diameter. 

Symphysis  Pubis. — The  fibro-cartilage  is  thicker  in  front  than 
behind,  and  towards  the  posterior  part  there  is  a  small  fissure, 
which  at  time  extends  throughout  the  whole  of  the  articulation  ; 
this  is  better  marked  in  the  female  than  in  the  male,  and  appears 
to  be  formed  by  the  softening  and  absorption  of  the  fibro-cartilage. 

Sacro-Cuccygeal  Articulation. — The  sacrum  is  joined  to  the  coccyx 
by  a  small  cartilaginous  disc  like  that  uniting  the  other  vertebrae, 
and  occasionally  there  is  a  similar  disc  between  the  first  and  second 


IS -6  cm 


Fig.  14. — Section  through  outlet  of  pelvis  to  show  the  diminution  of  the 
antero-posterior  diameter  of  the  outlet  by  1-3  cm.  in  the  horizontal  posi- 
tion and  rS  cm.  in  Walcher's  position  as  compared  with  the  lithotomy 
position.     (After  Kiittner.) 

bones  of  the  coccyx.  In  the  adult  woman  there  is  a  definite  cavity 
in  the  centre  of  the  intervertebral  disc  between  the  sacrum  and 
coccyx,  whereby  a  considerable  amount  of  forward  and  backward 
movement  is  allowed. 


Changes  in  Pelvic  Joints  during  Pregnancy. — In  pregnancy 
the  cartilages  and  fibrous  structures  become  swollen  and  softened, 
and  the  cavities  extended,  so  that  the  bones  are  separated  slightly 
further,  and  the  mobility  increased.  In  some  cases  this  process 
proceeds  to  a  morbid  degree,  or  persists  too  long  after  delivery. 
Walking  may  thus  be  painful  or  difficult  from  undue  mobility 
at  the  joints,  especially  at  the  symphysis  pubis.  In  some  animals 
the  changes  in  the  joints  are  of  more  importance  than  in  woman. 


Anatomy  of  the  Pelvis. 


13 


Thus,  in  guinea-pigs  wide  separation  takes  place  at  the  symphysis 
pubis  in  delivery,  and  in  the  sow  tilting  of  the  sacrum  materially 
enlarges  the  pelvic  canal. 

Mechanical  Action  of  the  Sacrum. — A  vertical  transverse 
section  of  the  pelvis  through  its  points  of  support  has  the 
form  of  an  arch,  both  in  the  standing  and  the  sitting  position ; 
these  points  of  support  being,  in  the  former  case,  the  acetabula,  in 
the  latter,  the  tubera  ischii.  There  is  no  mechanical  analogy, 
however,  to  an  arch    in   architecture,  for   the  opening  out  of  the 


Fig.  15. — Section  of  pelvis,  parallel  to  the  brim,  passing  through  the  points 
where  the  pelvis  rests  upon  the  heads  of  the  femora,  a  l.  Posterior 
sacro-iliac  ligaments. 


arch  is  not  prevented  by  any  lateral  support,  but  partly  by  the 
ring  of  the  pelvis  being  completed  at  the  symphysis  pubis,  and 
partly  by  the  strong  and  wide-spread  union  of  the  ilia  with  the 
sacrum.  Nor  has  the  sacrum  any  analogy  to  the  keystone  of  an 
arch,  although,  on  account  of  its  general  resemblance  to  a  wedge,  it 
was  formerly  compared  to  one.  It  has  been  shown  by  Matthews 
Duncan  that  its  action  is  rather  that  of  a  strong  transverse  beam, 
which  receives  the  weight  of  the  body  at  its  centre,  and  transmits 
it  at  its  extremities  to  the  iha. 

The  weight  of  the  body  may  (by  the  parallelogram  of  forces)  be 
considered  as  made  up  of  two  components,  one  tending  to  force  the 


14  The  Practice  of   Midwifery. 

sacrum  downward  and  forward  in  the  plane  of  the  pelvic  brim  (or 
in  the  direction  of  v  c  in  Fig.  11,  p.  8),  the  other  tending  to  force 
it  backward  at  right  angles  to  that  plane  (or  in  the  direction  of  the 
long  axis  of  the  sacrum  in  the  same  figure).  Taking  the  pelvic 
inclination  at  60°,  the  latter  force  is  exactly  half,  the  former  about 
four-fifths,  of  the  weight  of  the  trunk.^ 

A  section  through  the  centre  of  the  sacro-iliac  joint  parallel  to 
the  brim  of  the  pelvis  (Fig.  15,  p.  13)  shows  that  the  sacrum  is 
broader  below  than  above,  and  that  its  general  shape,  therefore,  is 
just  the  reverse  of  such  a  wedge-shape  as  would  be  required  to 
counteract  the  tendency  to  displacement  in  the  plane  of  the  brim. 
A  main  part  of  the  weight  is  in  fact  borne  by  the  posterior  sacro- 


FiG.  16. — Section  through  plane  of  pelvic  brim  or  superior  strait. 

iliac  ligaments  {a  h,  Fig.  15),  by  which  the  sacrum  is,  as  it  were, 
suspended  from  the  posterior  crests  of  the  ilia.  On  looking  at  the 
section,  however,  it  will  be  seen  that,  near  the  centre  of  the  joint, 
there  is  a  space  through  which  the  general  wedge-shape  of  the 
section  of  the  sacrum  is  reversed.  In  this  way  is  formed  a  notch, 
or  what  in  mechanics  is  called  a  "bite,"  which  is  of  great  import- 
ance in  keeping  the  bones  in  place.  Its  efficacy  is  increased  by 
the  fact  that  the  posterior  sacro-iliac  ligaments  slant  inwards,  from 
the  ilia  to  the  sacrum  (a  h,  Fig.  15),  and  thus,  in  proportion  to 
the  tension  which  is  put  upon  them,  they  draw  the  ilia  more 
strongly  together,  and  keep  the  articulating  surfaces  in  closer 
contact. 

1  The  exact  proportion  is  sin.  60°  or  '866. 


Anatomy  of  the  Pelvis. 


^5 


The  general  wedge-shape  of  the  sacrum  does  come  into  play 
in  preventing  its  displacement  downwards  and  backwards  per- 
pendicular to  the  plane  of  the  pelvic  brim.  The  tendency  to 
separation  of  the  ilia,  which  its  pressure  in  this  direction  would 
produce,  is  counteracted  as  before  by  the  slanting  direction  of  the 
posterior  sacro-iliac  ligaments  which  draw  the  bones  more  power- 
fully together  in  proportion  to  the  strength  of  the  displacing  force. 

Measurements  of  the  Pelvis. — The  dimensions  of  the  canal 
of  the  true  pelvis  may  be  estimated  by  drawing  any  number  of 
imaginary  planes  at  different  levels,  and  ascertaining  the  diameters 


2~D   SAC.  FOR. 


O.INT.- 


FlG.  17. — Section  through  plane  of  greatest  dimensions. 

of  each  plane.  Of  these  planes  the  most  important  are — first,  the 
plane  of  the  brim,  or  superior  strait  (Fig.  16) ;  secondly,  the  median 
plane  of  the  pelvic  cavity,  passing  through  the  centres  of  the  sacrum, 
and  of  the  symphysis  pubis  ;  and  thirdly,  the  plane  of  the  outlet,  or 
inferior  strait.  The  median  plane  intersects  the  obturator  foramen 
near  its  upper  part,  and  the  greater  sciatic  foramen  a  little  above 
its  centre,  crossing  the  ischium  above  the  level  of  its  spine.  (See 
Fig.  11,  p.  8.)  The  plane  of  greatest  pelvic  dimensions  does  not 
quite  correspond  to  the  median  plane  of  the  pelvis,  but  passes 
through  the  centre  of  the  symphysis  pubis,  the  junction  of  the 
second  and  third  sacral  vertebrae,  and  the  centre  of  the  acetabula 
(Fig.  17). 

The  plane  of  the  outlet  is  generally  regarded  as  drawn  through 
the  apex  of  the  pubic  arch  and  the  tip  of  the  coccyx.  Such  a  plane, 
however,  has  no  fixed  position,  but  varies  with  the  position  of  the 
coccyx ;  and,  further,  except  in  case  of  ankylosis  of  the  coccyx,  it 


1 6  The  Practice  of   Midwifery. 

is  the  plane  of  outlet  of  the  fixed  bony  pelvis,  terminating  at  the 
lower  extremity  of  the  sacrum,  which  determines  the  limit  of  size 
of  the  body  which  can  pass  out.  For  the  coccyx  can  be  pressed 
backward  until  the  antero-posterior  diameter  measured  from  its  tip 
exceeds  that  measured  from  the  lower  end  of  the  sacrum.  More- 
over, the  coccyx  being  thus  movable  and  virtually  endowed  with 
elasticity  in  virtue  of  its  connection  with  the  perineum  and  its 
muscles,  any  influence  which  it  exercises  upon  the  progress  of 
labour  is  comparable  rather  to  that  exercised  by  the  soft  parts  of 
the  perineum,  and  differs  totally  from  the  resistance  of  the  rigid 
portion  of  the  pelvis.  Hence  it  appears  preferable  to  regard  the 
plane  of  the  outlet  as  that  drawn  through  the  apex  of  the  pubic 
arch  and  the  lower  extremity  of  the  sacrum  (m  n.  Fig.  22,  p.  21). 


O.INT 


SY 

Fig.  18. — Section  through  plane  of  least  dimensions. 

Such  a  plane  is  inclined  about  16°  to  the  horizon,  assuming  the 
inclination  of  the  pelvic  brim  to  be  60°,  while  a  plane  drawn  through 
the  tip  of  the  coccyx  is  inclined  only  about  10°,  or  less,  according 
to  the  position  of  that  bone.  If  constructed  in  this  way  it  corre- 
sponds nearly  to  the  plane  of  least  pelvic  dimensions,  passing  laterally 
through  the  ischial  spines  (Fig.  18). 

Diameters  of  the  Pelvis. — In  each  plane  three  diameters  are 
generally  described,  the  antero-posterior,  the  oblique,  and  the 
transverse  (see  Fig.  6,  p.  4).  At  the  brim  the  term  conjugate  is 
frequently  applied  to  the  antero-posterior  diameter.  The  name 
is  taken  from  that  given  to  the  smallest  diameter  of  an  ellipse, 
and  should  not  therefore  be  extended,  as  it  sometimes  is,  to  the 
antero-posterior  diameters  in  the  cavity  and  at  the  outlet,  since 
these  are  not  the  smallest  in  their  respective  planes.     The  oblique 


Anatomy  of  the  Pelvis. 


17 


diameters  at  the  brim  are  drawn  from  a  point  on  the  iUo-pectineal 
line  a  little  in  front  of  the  sacro-iliac  joint  on  either  side  to  a  point 
corresponding  with  the  ilio-pectineal  eminence.  It  is  to  be  noted 
that  the  right  oblique  diameter  (r  o)  is  that  ivliiclL  starts  from  the 
right  sacro-iliac  joint,  and  the  left  oblique  (l  0)  that  ivhich  starts 
from  the  left  sacro-iliac  joint.  Some  confusion  has  arisen  from  the 
fact  that  some  French  authors  have  used  the  term  in  just  the 
opposite  sense,  naming  each  oblique  diameter  from  its  anterior 
instead  of  from  its  posterior  extremity.     Taking  the  average  of  a 


Fig.  19. — Section  of  pelvis,  side  to  side  ;  perpendicular  to  plane  of  brim. 

large  number  of  normal  pelves,  the  following  may  be  given  as  the 
standard  measurements,  taking  the  nearest  quarter  of  an  inch : — 


Anterc 

-posterioi 

Oblique. 

Transverse. 

ins. 

cms. 

ins. 

cms. 

ins. 

cms. 

Brim 

. 

4i 

=  11 

4| 

=    12 

?>l  = 

:13 

Cavity    . 

. 

4| 

=  12 

(5i) 

=  (13) 

4|  = 

:12 

Outlet     . 

. 

4i 

=  11-5 

m 

=  (11-5) 

4i- 

11 

Plane  of  greatest 

pelvic 

dimensions 

. 

5i 

=  13 

— 

5  = 

12-5 

Plane    of     least 

pelvic 

dimensions 

, 

4* 

=  11-5 

. — - 

4  = 

10-1 

The  oblique  diameters  at  the  cavity  and  the  outlet  are  enclosed 
in  brackets,  as  of  comparatively  little  importance,  since  their  length 
is  uncertain,  not  being  measured  between  bony  points. 

The  rhomboidal  opening  presented  by  the  pelvis  including  the 
coccyx,  when  looked  at  from  below  (Fig.  7,  p.  4),  does  not  lie  in 
one  plane,  the  tuberosities  of  the  ischia  being  on  a  lower  level  than 
the  line  joining  the  apex  of  the  pubic  arch  to  the  tip  of  the  coccyx. 

M.  2 


i8 


The  Practice  of  Midwifery. 


It  may  be  regarded  as  made  up  of  two  triangles,  one  side  being 
common  to  the  two,  namely,  the  transverse  diameter  between  the 
tuberosities  of  the  ischia,  the  apex  of  one  triangle  being  the  apex 
of  the  pubic  arch,  of  the  other  the  tip  of  the  coccyx. 
The  following  are  average  measurements  : — 


41=11 


31  =  9 


U~5  =  ll'5-12-5 


Between  ischial  tuberosities 
Antero-posterior   measured  to  tip   of 

coccyx     ...... 

This  may  be  increased  when  the  coccyx 

is  pushed  backward  in  parturition  to 

It  will  be  observed  that  the  transverse  diameter  is  progressively 
and  considerably  diminished  in  passing  from  the  brim  towards  the 

outlet,  the  effect  of  which  is  obvious 
on  looking  at  a  vertical  section  of 
the  pelvis  from  side  to  side  per- 
l^endicular  to  the  plane  of  the 
brim  (Fig.  19).  The  diminution 
is  chiefly  due  to  a  slightly  marked 
line  of  elevation  running  from  the 
brim  at  about  the  position  of  the 
ilio-pectineal  eminence  downward 
and  backward  to  the  ischial  spine, 
at  which  point  the  transverse 
diameter  in  the  plane  of  least  pelvic 
dimensions  is  the  smallest  of  all 
the  diameters  of  the  normal  pelvis, 
being  only  four  inches  (10-10*5 
cm.),  or  very  little  more.  On 
looking  at  a  lateral  view  of  the 
pelvis  from  within  (Fig.  20),  it  will 
be  seen  that  this  line  divides  the 
lateral  wall  into  an  anterior  and 
posterior  j)art.  Before  and  behind  this  elevated  line  are  two 
smooth  inclined  planes,  the  former  looking  slightly  forward,  the 
latter  slightly  backward.  These  are  the  anterior  and  posterior 
inclined  ]jlanes  of  the  ischium.  This  narrowing  of  the  lateral 
dimensions  of  the  pelvis  from  above  downwards  has  a  considerable 
influence  on  the  rotations  of  the  foetus  in  parturition.  The  view, 
however,  that  the  inclined  planes  play  an  imj)ortant  part  in  bringing 
about  the  rotation  of  the  foetal  head  has  been  abandoned  very 
largely,  and  it  is  probable  that  any  effect  they  may  have  is  but 
slight,  unless  the  foetal  head  fits  very  tightly  in  the  pelvis. 


Fig.  20. — Lateral  view  of  pelvis  from 
within,  showing  the  inclined 
planes  of  the  ischium. 


Anatomy  of  the  Pelvis.  19 

The  antero-posterior  diameter  becomes  considerably  increased  as 
it  is  traced  downward  from  the  brim  into  the  cavity  of  the  pelvis, 
but  is  diminished  again  rather  suddenly  when  the  inferior  strait  or 
plane  of  outlet  of  the  true  rigid  pelvis  is  reached.  Beyond  this 
point  it  is  again  somewhat  increased,  owing  to  the  mobility  of  the 
coccyx,  supposing  this  bone  to  be  pressed  backward  to  its  fullest 
extent.  The  diminution  which  the  antero-posterior  diameter 
undergoes  at  the  inferior  strait  does  not,  however,  alter  the  general 
result,  namely,  that  the  transverse  diameter  is  the  longest  at  the 
brim,  the  oblique  in  the  cavity,  and  the  antero-posterior  at  the 
outlet.  It  will  be  seen  hereafter  that  this  fact  is  of  great  import- 
ance in  determining  the  movement  of  the  foetal  head,  the  longest 
diameter  of  which  rotates  as  in  a 
screw,  following  the  longest  diameter 
of  the  pelvis. 

The  right  oblique  diameter  at  the 
brim  is,  as  a  rule,  slightly  longer  than 
the  left  (Fig.  21).  Two  causes  may 
contribute  to  this  result :  first,  the 
greater  use  of  the  right  leg,  leading 
to  a  greater  inward  pressure  at  the 
right  acetabulum,  and  a  consequent 
relative  shortening,  in  development,  Fig.  21.— Diagram  to  show  asym- 
of  the  left  obKque  diameter,  ending  ™*^J7  9j.Pei^\^  brim.  ;•  0., 

^  '  o  right   obhque  diameter ;  I.  o., 

at      that      acetabulum;      secondly,     a  left  oblique  diameter  ;  r.  *-.  c, 

congenital    asymmetry,   which    rans  iS^^'^S^^B^;;^ 

throughout     the     vertebral     column, 

including  the  cranial  bones,  and  in  virtue  of  which  that  column 
has  a  slight  tendency  towards  a  spiral  arrangement  instead  of 
being  perfectly  straight.  It  is  doubtful,  however,  whether  the 
right  leg  is  generally  stronger  than  the  left ;  and  whether  it  is  not 
rather  the  left  leg,  which  corresponds  to  the  right  arm,  with  which 
it  moves  synchronously. 

Alterations  of  Diameters  hy  Soft  Parts. — The  diameters  as  given 
above  are  measured  in  the  dry  pelvis,  and  the  presence  of  the  soft 
parts  introduces  modifications  of  some  importance,  especially  at  the 
pelvic  brim.  In  general  the  soft  parts  diminish  each  available 
diameter  about  ^  inch,  except  when  the  uterine  wall  intervenes 
between  the  presenting  part  and  the  pelvis,  in  which  case  the 
diminution  may  be  much  greater.  At  the  brim,  however,  the 
projections  of  the  psoas  and  iliacus  muscles  lessen  the  transverse 
diameter   about    \   inch.      In    the    clothed    pelvis,    therefore,    the 

1  Eaycr,  luc,  cit.  p.  lijy. 

2—2 


20  The  Practice  of  Midwifery. 

oblique  diameter  at  the  brim,  instead  of  being  smaller  than  the 
transverse,  is  about  equal  to  it. 

Other  Measurements. — Besides  the  diameters  already  given,  there 
is  another  which  has  considerable  practical  importance,  because  it 
can  readily  be  ascertained  in  the  living  woman.  This  is  measured 
from  the  apex  of  the  pubic  arch  to  the  promontory  of  the 
sacrum,  and  is  called  the  diagonal  conjugate  or  sacro-subpubic 
diameter  (e  n,  Fig.  22,  p.  21).  In  the  normal  or  slightly  contracted 
pelvis  it  is  about  two-thirds  of  an  inch  longer  than  the  true  con- 
jugate, and  therefore  measures  normally  4'90  inches  (12*5  cm.). 
Another  diameter  commonly  given  is  the  sacro-cotyloid  diameter 
(Fig.  21,  p.  19),  measured  from  the  promontory  of  the  sacrum 
to  a  point  corresponding  to  the  acetabulum  on  each  side.  It 
measures  normally  3-J  inches  (9  cm.).  The  cavity  of  the  pelvis 
is  much  deeper  posteriorly  than  anteriorly,  the  depth  from  the 
promontory  to  the  tip  of  the  sacrum  being  3f  inches  (9'5  cm.), 
or  to  the  tip  of  the  coccyx  4^  inches  (11  cm.),  while  the  depth  of 
the  symphysis  pubis  is  1^  inches  (4  cm.). 

External  Measurements. — The  external  measurements  of  the 
pelvis  are  only  of  significance  from  the  fact  that  inferences  may  be 
drawn  from  varieties  in  them  with  regard  to  the  magnitude  of 
internal  diameters.     The  following  are  average  measurements  : — 

ills.  cms. 

Between   antero-superior   spines  of   ilia    (Dist. 

Sp.  II.) 10-lOi  =  25-26 

Between  widest  part  of  iliac  crests  (Dist.  Cr.  II.)  11-11^  =  27-5-29 
External  conjugate  (C.  Ext.)  between  spine  of 

last    lumbar   vertebra   and   upper   border   of 

symphysis  pubis     ......  7|-8i    =  19-21 

Between  outer  surfaces  of  great  trochanters       .  12|-13  =  31-32 

Axis  of  the  Pelvis. — By  the  axis  of  the  pelvis  is  meant  an 
imaginary  line  indicating  the  course  taken  by  the  centre  of  the 
fcetal  head  as  it  passes  through  the  genital  canal.  This  course 
not  being  precisely  defined,  various  modes  have  been  given  for 
drawing  the  axis  of  the  pelvis.  Thus  the  centre  of  the  head  was 
supposed  to  move  in  what  was  called  the  circle  of  Carus,  a  circle 
having  its  centre  at  the  upper  margin  of  the  pubes,  and  a  radius 
equal  to  half  the  conjugate  diameter  of  the  brim.  But  the  inner 
surface  of  the  sacrum  is  almost  straight  in  vertical  section  so  far 
as  the  junction  of  its  second  and  third  bones,  and  the  inner  surface 
of  the  pubes  is  also  nearly  straight,  diverging  only  at  a  small  angle 
from  the  direction  of  the  surface  of  the  sacrum.     The  centre  of  the 


Anatomy  of  the  Pelvis. 


21 


head,  therefore,  in  the  first  part  of  its  course,  descends  almost  in  a 
straight  line,  as  through  a  cylinder,  until  it  is  low  enough  for  the 
bead  to  meet  the  resistance  of  the  curved  portion  of  the  sacrum, 
forming  part   of   the   pelvic   floor.     Its  course,  therefore,  has  no 


H 


.  R 


Fig,  22. — Diagram  showing  axis  and  planes  of  pelvis.  A  b  c,  axis  of 
pelvis  ;  C  D,  axis  of  developed  canal  of  soft  parts  ;  x,  anus  as  distended 
in  parturition  ;  E  F,  plane  of  brim  ;  K  L,  mid-plane  of  cavity  ;  M  N, 
plane  of  outlet  ;  o  P,  axis  of  brim  ;  Q  R,  axis  of  mid-plane  ;  s  T,  axis 
of  outlet ;  H  H,  horizon  ;  E  N,  diagonal  conjugate  or  sacro-subpubic 
diameter. 

resemblance  to  the  arc  of  a  circle,  neither  does  it  resemble  a 
parabola,  to  which  it  has  been  compared,  for  the  two  arms  of  a 
parabola  tend  towards  directions  parallel  to  each  other,  if  produced 
far  enough. 

The  following  construction  for  drawing  the  pelvic  axis  will  give 
a  line  closely  approximating  to  the  path  of  the  centre  of  the  foetal 


22  The  Practice  of  Midwifery. 

bead.  Through  the  promontory  of  the  sacrum  draw  a  line  e  f 
(see  Fig.  22,  p.  21),  not  to  the  absolute  summit  of  the  symphysis 
pubis,  but  to  the  nearest  point  of  the  symphysis.  This  line  repre- 
sents the  smallest  diameter  through  which  the  fcetus  has  to  i^ass 
at  the  brim,  and  therefore  most  rightly  deserves  the  name  of  the 
true  conjugate  diameter.  It  is  sometimes  called  the  obstetric  true 
conjugate  diameter,  to  distinguish  it  from  a  line  drawn  to  the 
absolute  summit  of  the  symphysis,  as  in  Fig.  11  (p.  8).  The 
plane  passing  through  e  f  perpendicular  to  the  plane  of  the  figure 
is,  for  practical  purposes,  the  plane  of  the  pelvic  brim.  Similarly, 
if  M  N  be  drawn  from  the  tip  of  the  sacrum  to  the  nearest  point  at 
the  bottom  of  the  symphysis  i^ubis,  m  n  is  the  smallest  antero- 
posterior diameter  at  the  inferior  strait,  and  the  plane  passing 
through  M  N  perpendicular  to  the  plane  of  the  figure  is  the  plane 
of  the  pelvic  outlet. 

From  the  point  in  front  of  the  pubes  where  e  f  and  m  n  meet, 
let  any  number  of  radii  be  drawn  intersecting  the  pubes  and  the 
sacrum,  and  let  a  line  a  b  c  be  drawn,  passing  through  the  centres 
of  all  those  portions  of  the  radii  which  are  intercepted  between  the 
inner  surfaces  of  the  pubis  and  sacrum.  The  line  a  b  c  will  be  the 
axis  of  the  bony  pelvis.  The  upper  half  of  it,  a  b,  will  be  almost 
a  straight  line,  since  the  upper  half  of  the  anterior  face  of  the 
sacrum  is  nearly  straight.  If  r  l  be  a  radius  midway  between  e  f 
and  M  N,  the  plane  passing  through  k  l  perpendicular  to  the  plane 
of  the  figure  will  be  the  mid-plane  of  the  pelvic  cavity. 

The  construction  may  be  completed  in  the  following  manner  for 
the  variable  portion  of  the  genital  canal.  Suppose  the  coccyx  to  be 
pushed  back  as  in  jjarturition,  and  the  soft  part  of  the  canal  to  be 
dilated  to  the  full  expansion  reached  as  the  foetal  head  is  passing 
through  it.  The  curve  of  the  posterior  wall  of  the  canal  will  thus 
be  an  arc  of  a  circle  having  its  centre  near  the  lowest  point  of  the 
symphysis  pubis,  and  the  axis  of  the  canal  of  soft  parts,  including 
the  coccyx,  will  be  an  arc  of  a  circle  c  d,  having  the  same  centre 
and  half  the  radius.  At  c  there  is  a  point  of  discontinuity 
between  the  axis  of  the  bony  pelvis  and  that  of  the  canal  of  soft 
parts.  At  this  point  the  centre  of  the  head  slightly  changes  its 
direction  of  movement  on  passing  the  inferior  strait,  having  just 
previously  been  compelled  to  approach  nearer  to  the  pubes,  on 
account  of  the  progressive  diminution  of  the  antero-posterior 
diameter. 

Axes   of    the    several   Planes   of   the   Pelvis. — It   has   been 
usual  to  regard  the  axis  of  each  plane  as  a  straight  line  drawn 


Anatomy  of  the  Pelvis.  23 

at  right  angles  to  that  plane  through  its  centre.  Such  a  line,  how- 
ever, has  no  practical  significance  or  use.  "What  we  want  to  know 
is  the  direction  in  which  the  centre  of  the  head  is,  or  ought  to  be, 
advancing,  when  that  centre  lies  in  any  given  plane  of  the  pelvis. 
This  direction  will  be  given  if  we  define  the  axis  of  any  plane  as 
the  tangent  to  the  curved  axis  of  the  pelvis  at  the  point  where  it 
cuts  that  plane.  This  is  the  same  thing  as  the  straight  line  joining 
the  centres  of  two  very  closely  adjacent  planes,  and  it  therefore 
necessarily  gives  the  direction  of  motion  of  the  centre  of  the  head. 
As  thus  defined,  the  axis  coincides  with  the  line  drawn  at  right 
angles  to  the  plane  at  the  brim,  but  at  other  parts,  especially 
towards  the  inferior  strait,  this  is  not  precisely  so.  In  Fig.  22, 
0  p  is  the  axis  of  the  brim,  q  e,  the  axis  of  the  mid-plane,  is 
inclined  only  slightly  to  the  axis  of  the  brim,  on  account  of 
the  slight  curvature  of  a  b,  the  upper  part  of  the  pelvic  axis. 
s  T,  the  axis  of  the  outlet,  which  indicates  the  line  of  movement 
of  the  centre  of  the  fcEtal  head  as  it  approaches  the  outlet,  differs 
appreciably  from  the  straight  line  drawn  at  right  angles  to  the 
plane  of  the  outlet,  and  is  nearly  coincident  with  the  vertical  axis 
of  the  woman. 

The  Pelvis  in  Infancy  and  Childhood. — In  infancy  the 
pelvis  is  very  small,  even  in  proportion  to  the  size  of  the  child, 
and  thus  the  organs  afterwards  contained  in  the  pelvis  are,  in  the 
infant,  partially  in  the  abdomen.  The  prominence  of  the  abdomen 
noticed  in  early  life  is  thus  accounted  for.  Besides  its  small  size, 
the  pelvis  of  the  infant  difi'ers  in  shape  from  that  of  the  adult,  and 
departs  less  widely  from  the  type  of  pelvis  seen  in  animals  (see 
Fig.  10,  p.  7).  The  iliac  fossae  are  flatter  and  less  spread  out,  more 
upright,  and  their  surfaces  look  more  forward.  The  maximum 
distance  between  the  iliac  crests  is  hardly  greater  than  that 
between  the  antero-superior  spines.  It  has  generally  been  said 
that  the  sacrum  is  narrower  in  proportion  than  in  the  adult  pelvis, 
but  Professor  Thomson  has  shown  that  the  reverse  is  the  case,  its 
width  in  the  foetus  exceeding  the  transverse  diameter  of  the  brim. 
The  maximum  width  lies,  however,  more  above  the  plane  of  the 
brim  than  in  the  adult;  and  the  wings  are  less  developed  in 
proportion  to  the  body.^  Most  writers  maintain  that  the  antero- 
posterior diameter  of  the  brim  exceeds  the  transverse  in  the  fcetal 
and  infantile  pelvis,  and  this  is  the  case  with  many  dried  specimens. 
According  to  Thomson,  however,  this  is  not  correct ;  and  he  finds 
the  excess  of  the  transverse  diameter  to  be  little  less  in  the  fcetal 

J  Journal  of  Anuloriiy  and  Pliysiology,  1898—99,  Vol.  XXXIII..  \>.  859. 


24 


The  Practice  of  Midwifery. 


than  in  the  adult  pelvis.  The  pelvis  is  funnel-shaped,  becoming 
smaller  towards  the  outlet  in  the  female  sex  as  well  as  in  the  male. 
The  curve  of  the  sacrum,  in  antero-posterior  section,  is  very  slight, 
and  the  sacro-vertebral  angle  is  less  than  in  the  adult,  so  that  the 
anterior  surface  of  the  sacrum  looks  more  forwards  and  not  so 
much  downwards.  The  transverse  concavity  of  its  anterior  surface 
is  greater  than  in  the  adult,  while  it  is  less  deeply  sunk  between 
the  iliac  bones  in  the  direction  of  the  coccyx.  The  curvature  of 
the  ilio-pectineal  lines  is  slighter.  The  pubic  arch  forms  a  more 
acute  angle,  and  the  tubera  ischii  are  relatively  nearer  together 
than  in  the  adult.  The  three  portions  of  the  innominate  bone, 
separated  by  a  triradiate  or  Y-shaped  piece  of  cartilage,  having  its 


Fig.  23. — Pelvis  of  foetus  viewed  in  the  axis  of  the  brim. 


centre  at  the  acetabulum,  are  not  united  into  a  solid  bone  till  about 
the  twentieth  year,  an  arrangement  which  permits  the  prolonged 
enlargement  of  the  pelvis  by  growth.  It  has  been  said  that  there 
is  little  or  no  distinction  between  the  male  and  female  pelvis  in 
foetal  life  and  childhood,  but,  according  to  Fehling's  researches, 
the  distinctions  of  sex  are  manifested  much  earlier  than  has  been 
supposed,  even  at  the  fifth  month  of  foetal  life.  The  special 
characters  of  the  female  pelvis,  especially  its  relatively  large  size, 
are  not,  however,  fully  manifested  until  the  time  of  puberty  is 
drawing  near.  About  this  time  a  specially  rapid  growth  takes 
place  in  the  female,  except  in  those  cases  in  which  there  is 
congenital  deficiency  of  uterus  and  ovaries.  This  is  one  of  the 
facts  which  show  that   the   development   of   the   pelvis    depends 


Anatomy  of  the  Pelvis. 


25 


largely  upon  the  original  forces  of  growth,  and  not  merely  upon 
mechanical  influences. 

Development  of  the  Pelvis. — The  changes  in  shape  which  the 
pelvis  undergoes  during  growth  are  brought  about  partly  by  the 
development  of  the  several  bones,  and  partly  by  the  action  of 
mechanical  forces.  The  characteristic  differences  of  sex  depend 
upon  the  former,  and  are  already  manifest  in  fcetal  life.  The  latter 
act  equally,  or  almost  equally,  upon  the  two  sexes.     It  is  of  special 


Fig.  24. — Antero-posterior  section  of  adult  pelvis  with  foetal  pelvis  (enlarged) 
si;perimposed  to  show  changes  in  position  of  sacrum.  Dotted  out- 
line =  adult  pelvis ;  continuous  outline  =  pelvis  of  fcetus  of  seventh 
month.     Angle  of  pelvic  brim  in  adult  60°  ;  in  foetus  84°. 

importance  to  study  carefully  the  action  of  these  influences  in  the 
development  of  the  normal  pelvis,  for  if  this  be  once  thoroughly 
understood,  the  mode  in  which  all  the  forms  of  distorted  pelvis 
result  from  modifications  of  these  influences  will  present  no  difii- 
culty.  The  most  important  mechanical  influence  is  exerted  by  the 
weight  of  the  body  transmitted  through  the  sacrum,  from  the  effect 
of  which  the  bones  become  gradually  moulded  in  the  course  of 
years.  The  pressure  and  tension  of  muscles  and  ligaments  have 
also  considerable  influence. 

Changes  in  the  Sacrum. — The  vertical  line  through  the  centre  of 
gravity  of  the  body  passes  nearly  through  the  promontory  of  the 


26  The  Practice  of  Midwifery. 

sacrum,  and  therefore  in  front  of  the  centre  of  the  sacro-ihac  jomt 
(r  /,  Fig.  11,  p.  8).  The  effect  of  the  weight  therefore  tends  to 
rotate  the  iDromontory  of  the  sacrum  forward  and  downward  upon  a 
transverse  axis  through  the  centre  of  the  sacro-ihac  joint.  The 
lower  extremity  of  the  bone  would  be  tilted  bach  in  corresponding 
degree  but  for  the  tension  of  the  sacro-sciatic  ligaments.  The 
effect  of  the  two  forces  acting  in  conjunction  is  that  the  curva- 
ture of  the  sacrum,  in  antero-posterior  section,  is  increased,  while 
the  sacro-vertebral  angle  becomes  more  acute,  and  the  upper  part 
of  the  anterior  surface  of  the  sacrum  approaches  nearer  to  the  hori- 
zontal. Besides  this,  each  of  the  two  components  of  the  body-weight, 
one  acting  perpendicular  to  the  pelvic  brim,  the  other  in  the  plane 
of  the  brim,  has  an  effect  upon  the  sacrum.  The  first  causes  it  to 
sink  deeper  downward  and  backward  between  the  ilia,  so  that  the 
j)romontory  approximates  more  nearly  than  before  to  the  plane  of 
the  brim  (Fig.  24).  The  second  and  larger  component  causes  it  to 
sink  slightly  towards  the  centre  of  the  brim,  so  that  the  posterior 
crests  of  the  ilia  stand  out  further  behind  it.  It  also,  through 
yielding  of  the  bone,  diminishes  its  curvature  in  transverse  section, 
and  thus  flattens  that  part  of  the  circumference  of  the  brim  formed 
by  the  sacrum.  (See  Fig.  25.)  This  effect  is  increased  if  the 
bone  is  unduly  soft,  as  from  rickets,  and  the  promontory  then 
becomes  an  actual  projection  inwards  into  the  brim. 

As  regards  the  changes  in  the  sacrum  due  to  growth,  the  chief 
difference  noted  in  the  adult  pelvis  is  that  the  wings  of  the  sacrum 
have  developed  more  in  proportion  than  the  central  portion.  (Com- 
pare Figs.  6,  p.  4,  and  28,  p.  24.)  It  has  generally  been  stated  that 
this  development  of  the  sacral  wings  produces  a  relative  increase  of 
the  transverse  diameter  of  the  pelvis.  According  to  Thomson, 
however  {be.  cit.),  the  growth  of  the  sacrum  as  a  whole  is  so  much 
less  than  that  of  the  ilia,  that,  notwithstanding  the  development  of 
the  wings,  the  total  transverse  width  is  less  in  proportion  to  the 
brim  in  the  adult  than  in  the  foetus.  So  far  as  the  growth  of  the 
sacrum  is  concerned,  therefore,  the  preponderance  of  the  transverse 
over  the  conjugate  diameter  would  tend  to  diminish.  It  is  probable 
that  it  actually  does  diminish  in  the  earlier  years  as  a  result  of  the 
more  raj)id  growth  of  the  ilia,  and  thus  a  pelvis  in  which  the  trans- 
verse has  not  the  same  preponderance  over  the  conjugate  as  in  the 
adult  is  characteristic  rather  of  the  child  than  of  the  foetus  or  infant, 
as  was  formerly  supposed.  When  the  more  rapid  growth  of  the 
wings  of  the  sacrum  takes  place  near  the  time  of  puberty,  the 
transverse  diameter  regains  its  preponderance,  aided  by  the  action 
of  mechanical  forces.     If  any  cause  prevents  the  development  of  the 


Anatomy  of  the  Pelvis. 


27 


sacral  wings,  marked  transverse  narrowing  in  the  adult  pelvis  is  the 
result. 

Changes  in  the  Lateral  Pelvic  Wall. — It  has  been  already- 
explained  that  a  main  part  of  the  weight  of  the  body  is  suspended 
from  the  posterior  crests  of  the  ilia  by  the  posterior  sacro-iliac 
ligaments  (see  pp.  13,  14).  Its  effect  upon  the  shape  of  the  brim 
may  be  studied  by  examining  a  section  parallel  to  the  brim,  through 
the  points  of  support  of  the  acetabula  upon  the  heads  of  the  femora, 
a  section  which  passes  also  nearly  through  the  centre  of  the 
sacro-iliac  joint  and  its  posterior  Hgaments.  (See  Fig.  15,  p.  13, 
and  Fig.  25.) 

The  innominate  bone  (a  d  ^,  Fig.  25),  hinged  upon  the  sacro-iliac 
joint  (c),  forms  a  lever,  whose  fulcrum  is  the  joint  c.     The  posterior 


Fig.  25. — Diagram  to  illustrate  the  change  of  shape  in  the  pelvis.  The  figures  are 
supposed  to  be  sections  parallel  to  the  plane  of  the  brim,  passing  through  the 
points  where  the  pelvis  rests  on  the  heads  of  the  femora,  like  the  actual  section 
shown  in  Fig.  15,  p.  13. 

A.  Child's  pelvis.  B.  Mature  pelvis  reduced  to  size  of  child's  pelvis. 

a  h.  Posterior  sacro-iliac  ligaments.  d.  Point  at  which  pelvis  rests  on  head 

c.  Sacro-iliac  articulation.  of  femur. 

e.   Symphysis  pubis. 
P,  Q.  Components  of  pressure  of  head  of  femur. 

extremity  («)  of  the  lever  is  drawn  forwards  and  inwards  through 
the  x^osterior  sacro-iliac  ligaments  {a  h)  by  that  component  of  the 
body- weight  which  acts  parallel  to  the  brim.  The  anterior  end  (e) 
of  the  lever  would  therefore  be  tilted  outward,  on  an  axis  perj)en- 
dicular  to  the  brim  passing  through  the  fulcrum  c,  but  that  it  is 
held  inward  by  the  symphysis  pubis.  As  it  is,  the  bone  is  gradually 
moulded  and  its  curvature  increased,  so  as  to  enlarge  the  transverse 
diameter  of  the  pelvis. 

In  Fig.  25  is  shown  diagrammatically  the  change  of  shape 
produced  by  the  body-weight  in  the  advance  from  infancy  to 
maturity.  The  actual  change,  as  shown  in  the  figure,  is  exagge- 
rated, according  to  modern  views  as  to  the  true  shape  of  the  infantile 
pelvis,  since  the  transverse  exceeds  the  conjugate  diameter  even  in 
infancy.     Comparing  a  with  a,  it  will  be  seen  that  in  b  the  sacrum 


28  The  Practice  of  Midwifery. 

has  become  flattened,  and  has  sunk  deeper  between  the  ilia.  The 
lateral  walls  of  the  pelvis  have  become  more  curved,  and,  in 
consequence,  the  transverse  diameter  has  become  relatively  greater. 

Efects  of  the  Pressure  of  the  Femora. — The  tilting  outward  of  the 
anterior  end  of  the  lever  is  resisted,  not  only  by  the  completion  of 
the  pelvic  ring  at  the  symphysis  pubis,  but  by  the  inward  pressure 
of  the  heads  of  the  femora  at  the  point  d  (Fig.  25).  So  far  indeed 
as  this  pressure  is  the  reaction  to  the  weight  of  the  body,  it  acts 
vertically  upwards  (p,  Fig.  25).  This  is  evident  if  the  equilibrium 
of  the  leg  is  considered.  The  resistance  of  the  ground,  by  which 
the  weight  of  the  body  is  supported,  acts  vertically  upwards.  For 
equilibrium  this  line  of  action  must  coincide  with  the  line  in  which 
the  weight  of  the  body  is  transmitted  downward  to  the  head  of  the 
femur.  It  therefore  tends  to  thrust  the  acetabulum  d  not  inward, 
but  outward.  For  the  projection  of  its  direction  on  the  plane  of 
Fig.  25,  being  a  vertical  line  (p),  will  fall  outside  the  sacro-iliac 
joint  or  fulcrum  c.  The  force  p  will,  therefore,  tend  to  rotate  the 
lower  end  of  the  innominate  bone,  or  lever  a  d  e,  outward. 

The  pressure  of  the  head  of  the  femur  has,  however,  also  a 
horizontal  component  q,  acting  inward  at  the  point  d.  This  is  due 
to  the  horizontal  component  of  the  tension  of  the  muscles  which 
slant  inward  from  the  femur  to  the  pelvis.  It  is  to  be  observed  also 
that  the  perpendicular  from  the  fulcrum  c  (Fig.  25)  on  the  direction 
of  the  force  q  is  much  greater  than  that  on  the  direction  of  p.  The 
force  Q  has  therefore  in  this  respect  a  mechanical  advantage  in 
leverage  over  the  force  p.  Inward  pressure  at  the  acetabulum  is 
also  produced  in  lying  on  the  side.  It  would  be  impossible  to 
calculate  d  2Jriori  whether  on  the  whole  the  inward  or  outward 
leverage  would  preponderate.  But  experience  shows  that  the 
inward  leverage  does  actually  preponderate.  This  is  proved  by  the 
fact  that,  in  persons  w'ho  sit  much  and  stand  or  walk  little,  as,  for 
instance,  children  who  suffer  severely  from  rickets,  the  pelvis 
becomes  relatively  wider,  from  diminished  action  of  the  pressure  of 
the  femora.  It  is  also  proved  especially  by  two  rare  forms  of 
pelvis.  The  first  is  that  in  which  the  legs  are  congenitally  absent, 
but  the  woman  is  able  to  sit  upon  the  tubera  ischii.  The  second 
is  that  of  the  so-called  congenital  dislocation  of  both  femora,  really 
a  malformation,  in  which  no  acetabula  are  developed,  but  the  heads 
of  the  femora  rest  on  the  outside  of  the  expansions  of  the  ilia.  In 
both  these  forms  of  pelvis,  the  transverse  diameter  is  relatively 
large,  in  consequence  of  the  absence  of  the  pressure  of  the  femora 
at  the  acetabula. 

Since   therefore  the  tension  of  the  sacro-iliac  ligaments   (a  h, 


Anatomy  of  the  Pelvis.  29 

Fig.  25)  is  resisted  both  by  the  inward  thrust  at  d  and  by  the 
tension  at  e,  the  iUum  is  the  portion  of  the  innominate  bone  which 
is  most  strongly  acted  upon  between  the  counteracting  forces,  and 
thus  it  is  at  the  posterior  part  of  the  lateral  wall  between  c  and  d 
that  the  curvature  of  the  brim  is  most  increased.  The  effect 
extends  also  to  the  crest  of  the  ilium,  which  gains  in  this  way 
that  curvature  owing  to  which  the  maximum  transverse  diameter 
(Dist.  Cr.  II.)  comes  to  exceed  the  distance  between  the  antero- 
superior  spines  (Dist.  Sp.  II.).  The  inward  pressure  of  the  femora 
is  not  in  itself,  without  the  effect  of  the  junction  at  the  symphysis 
pubis,  sufficient  to  counteract  the  tilting  outward  of  the  anterior 
end  of  the  lever,  as  is  proved  by  the  fact  that  the  acetabula  do 
actually  become  relatively  further  apart,  and  the  anterior  half  of 
the  pelvic  ring  has  its  share  in  the  moulding  produced.^ 

The  ilium  alone  has  been  regarded  as  forming  the  lever,  and 
termed  the  "  sacro-cotyloid  beam."  All  the  parts  of  the  innominate 
bone,  however,  react  upon  each  other,  even  though  the  union 
between  them  is  only  by  cartilage,  as  is  proved  by  the  fact,  already 
mentioned,  that  the  development  of  the  curvature  of  the  brim 
takes  place  even  in  the  absence  of  an  acetabulum.^  There  is 
another  reason  why  it  is  mechanically  unsound  to  regard  the  ilium 
alone  as  the  lever.  For,  since  there  is  more  or  less  rigid  union 
between  ilium  and  pubes,  the  action  betweto  the  two  cannot  be 
reduced  to  a  single  resultant  force,  but  only  to  a  force  and  a 
couple,  while  the  direction  of  the  couple  cannot  be  determined. 
But  at  the  point  e,  where  the  two  pubic  bones  are  united,  it  is 
obvious  from  symmetry  that  the  action  between  the  two  in  the 
standing  position  is  reduced  to  a  single  horizontal  force,  and  that 
the  couple  vanishes. 

The  leverage  action  in  widening  the  pelvis  being  dependent  upon 
the  component  of  the  body-weight  which  acts  parallel  to  the  plane 
of  the  brim,  it  follows  that  the  effect  is  increased  with  any  increase 
of  the  inclination  of  the  brim,  and  the  converse.  Hence  we  get  a 
general  principle  which  it  is  of  great  importance  to  remember  in  all 
pelvic  deformities.     Any  deformity  which  increases  the  inclination  oj 

1  For  a  discussion  of  the  effect  of  the  pressure  of  the  femora,  see  Champneys,  Trans. 
Obst.  Soc.  London,  1883,  Vol.  XXV.,  p.  70. 

2  Matthews  Duncan,  in  his  able  discussion  of  this  suVjject,  committed  one  error,  when 
he  assumed  that  the  direction  of  tlie  necli  of  the  femur  indicates  the  direction  of  the 
resultant  pressure  of  the  head  of  the  femur  upon  the  pelvis  (Researches  in  Obstetrics, 
p.  106).  There  is  no  reason  why  it  should  indicate  this  direction,  since  the  force  is 
transmitted  just  as  if  the  femur  formed  a  straight  line,  and  that  it  does  not  do  so  is 
proved  by  the  change  in  the  direction  of  the  neck  of  the  femur  which  sometimes 
occurs  in  old  age,  when  its  inclination  to  the  vertical  becomes  more  obtuse.  This 
shows  that  the  average  diiection  of  the  resultant  pressure  of  the  pelvis  upon  the  head 
of  the  femur  is  not  in  the  line  of  the  neck,  but  more  nearly  vertical. 


30  The  Practice  of  Midwifery. 

the  brim,  tends  to  ijroduce  a  relatively  great,  and  any  deformity  ivhich 
dinmiishes  it,  to  produce  a  relatively  small,  transverse  diameter. 

Effects  of  Sitting. — In  sitting  the  reactions  to  the  weight  of  the 
body  act  vertically  upwards  through  the  tubera  ischii.  The  pro- 
jections of  these  vertical  lines  upon  the  plane  parallel  to  the  brim 
through  the  centres  of  the  sacro-iliac  joints  pass  outside  those 
joints,  just  as  the  line  p  does  in  Fig.  25,  p.  27,  the  tubera  ischii 
being  further  apart  than  the  sacro-iliac  joints.  Hence  the  effect  of 
the  pressure  tends  to  rotate  the  anterior  end  of  the  lever  formed  by 
the  innominate  bone  outward,  and  thus  increase  relatively  the 
transverse  diameter  of  the  pelvis.  In  persons,  therefore,  who 
cannot  stand  or  walk  during  the  age  of  development,  but  sit  a  great 
deal,  the  pelvis  is  generally  wider  than  normal.  For  the  body- 
weight  tends  to  widen  the  pelvis  by  leverage,  as  in  standing, 
although  in  somewhat  less  degree,  on  account  of  the  diminished 
pelvic  inclination ;  and  this  tendency  is  assisted  by  the  pressure  on 
the  tubera  ischii,  instead  of  being  counteracted  in  some  measure  by 
pressure  on  the  acetabula.  On  the  other  hand,  the  pelvis  of  a 
woman  bedridden  from  birth,  who  never  sat  or  walked,  has  been 
described  in  which  the  antero-posterior  diameter  at  the  brim  is 
considerably  greater  than  the  transverse  (see  Chapter  XXX.) ;  while 
the  outlet  is  small,  somewhat  like  that  of  a  male  pelvis. 

Again,  since  the  vertical  line  through  the  tubera  ischii  passes 
outside  a  line  joining  the  centres  of  the  symphysis  pubis  and  of  the 
sacro-iliac  joint,  the  pressure  on  the  tuber  tends  to  rotate  the 
lower  part  of  the  innominate  bone  outward  upon  this  line  as  axis. 
Movement  of  the  whole  bone  being  resisted  by  the  ligaments,  the 
ischia  become  bent  somewhat  outwards,  and  the  distances  between 
their  tubera  relatively  wider,  as  the  pelvis  grows.  The  action  of 
the  muscles  passing  from  the  ischium  and  from  the  lower  ramus  of 
the  pubes  to  the  femur  also  tends  to  draw  the  ischium  outwards, 
and  to  widen  the  pubic  arch.  The  same  forces  which  widen  the 
distance  between  the  tubera  ischii  also  counteract  the  tendency 
which  the  tension  of  the  lesser  sacro-sciatic  ligaments  would 
otherwise  have  to  approximate  the  spines  of  the  ischia. 

Effects  of  Muscular  Action. — The  plane  of  the  abdominal  muscles 
attached  to  the  anterior  half  of  the  pelvic  ring  is  inclined  backward 
in  reference  to  the  axis  of  the  brim.  Of  these  muscles,  the  recti 
are  the  most  powerful.  Thus,  the  traction  force  exercised  by  these 
muscles  has  a  component  acting  in  the  plane  of  the  brim  and  tend- 
ing to  pull  the  pubes  backward  toward  the  sacrum,  and  thus  flatten 
the  pelvic  ring  from  before  backward  and  spread  it  out  laterally. 
This   force  aids  the  effect  of  the  body-weight   in   promoting   the 


Anatomy  of  the  Pelvis.  31 

transverse  development  of  the  pelvis.  It  is  probably  due  to  the 
same  force  that,  in  intra-uterine  rachitis,  before  the  body-weight 
can  have  any  influence,  the  characteristic  rachitic  shape  of  brim  is 
produced.  The  psoas  and  iliacus  muscles  also  tend  to  draw  the 
superior  half  of  the  pelvic  ring  toward  the  inferior,  and  so  to  flatten 
the  pelvis. 

The  change  of  shape  of  the  iliac  fossse,  by  which  they  become 
more  curved  and  more  hollow  and  look  more  uj)wards  than  in 
infancy,  is  promoted  by  the  traction  of  the  muscles  attached  to 
them,  especially  the  glutei  and  sartorius,  as  well  as  by  the  leverage 
exercised  on  the  ilia  by  the  posterior  sacro-iliac  ligaments. 

The  doctrine  that  the  weight  of  the  body  is  the  most  important 
of  the  influences  determining  the  normal  development  of  the  adult 
out  of  the  infantile  pelvis,  and  also  the  production  of  certain  forms 
of  pelvic  deformity,  especially  of  the  rachitic  pelvis,  is  supported  by 
Litzmann,^  Matthews  Duncan,^  and  Schroeder.^  On  their  authority 
it  has  obtained  wide  acceptance.  Ivehrer,*  however,  has  argued 
that,  because  many  of  the  changes  characteristic  of  rickets  have 
been  found  in  congenital  cases,  when  the  body- weight  can  have  had 
no  influence,  the  action  of  the  muscles  must  be  the  most  important 
element  in  the  case.  Fehling  ^  also  contends  against  the  doctrine 
of  the  influence  of  the  body-weight  in  the  normal  development,  and 
in  the  production  of  the  rickety  pelvis ;  and,  as  to  the  formation  of 
the  latter,  attaches  the  chief  importance  to  arrest  or  disturbance  of 
development. 

The  view  that  the  tendency  of  the  growth  of  the  bones  plays  a 
leading  part  in  the  development  of  the  pelvis  is  supported  by  the 
fact,  already  mentioned,  that  in  the  young  female  child  of  eight  to 
twelve  years  of  age  the  pelvic  inlet  has  a  somewhat  oval  form,  and 
the  conjugate  diameter  is  longer  in  relation  to  the  transverse  than 
it  is  in  the  fcetus  or  the  adult,  no  doubt  as  a  result  of  the  more 
rapid  growth  of  the  ilia. 

Breus  and  Kolisko  ^  maintain  that  the  forces  of  the  growth  of  the 
bones  are  all-important,  and  lay  great  stress  upon  the  effects 
produced  by  inequalities  in  the  rate  of  growth  both  of  the  sacrum 
and  of  the  component  parts  of  the  ilium  in  the  development  of 

'  Litzmann,  Die  Formen  des  Beckens,  Berlin,  1861. 

'■^  M.  Duncan,  Researches  in  Obstetrics,  EdinVjurgh,  1868. 

"  Hchroeder,  Lehrbuch  der  Geburtshiilfe,  Bonn,  1882.     7th  Aufl. 

*  Kehrer,  Zur  EntvvickelungsKoschichte  des  Kachitischen  Beckens,  Arch,  filr 
Gyniik.,  Band  V.,  Hft.  I.,  p.  .55,  1873. 

^  Fehling,  Die  Form  des  Beckens  beim  Fbtus  und  Neugeborenen.  Arch.  fLir 
Gyniik.,  Band  X.,  Hft.  I.,  p.  ],  1876;  iJic  Entstchung  der  Rachitischen  Beckens. 
Arch,  fiir  Gyniik.,  Band  XI.,  lift.  !.,  p.  173,  1877. 

«  Die  Patholugischen  Jieckeiiformen,  Leipzig,  I'JOO,  Bd.  I.,  Th.  1,  1904,  Th.  2. 


32  The  Practice  of  Midwifery. 

the  normal  and  abnormal  type  of  j)elvis.  According  to  them,  the 
more  raj)id  growth  of  the  ilium  in  the  early  years  of  life  tends  to 
produce  the  oval  shape  of  the  pelvic  inlet  in  the  young  child, 
the  occurrence  of  which  is  difficult  to  explain  on  the  assump- 
tion that  it  is  due  to  the  action  of  the  body- weight.  If  this  were 
so,  then  a  progressive  flattening  of  the  pelvis  should  take  place 
from  foetal  up  to  adult  life,  which  is  not  the  case,  since  the  action 
of  the  body- weight  comes  into  play  at  a  very  early  period,  affects 
both  sexes  equally,  and  continues  to  act  so  long  as  the  individual  is 
able  to  walk  of  sit. 

We  are  quite  ignorant  concerning  the  nature  of  the  conditions 
which  influence  the  rate  of  growth  of  the  different  constituent 
bones  of  the  pelvis,  and  no  satisfactor}^  explanation  of  them  has 
been  given  hitherto  ;  but  in  any  consideration  of  the  evolution 
of  the  adult  pelvis  such  inequahties  in  the  rate  of  growth  of  the 
bones  at  different  periods  of  life  cannot  be  ignored,  and  must 
certainly  be  regarded  as  a  most  important  factor. 

It  must  be  admitted,  therefore,  that  both  the  forces  of  growth 
and  the  action  of  muscles  are  of  much  importance,  and  that 
MattheW'S  Duncan  and  Schroeder  have  attached  too  exclusive  an 
influence  to  the  leverage  action  of  the  "  sacro-cotyloid  beam." 
But  it  does  not  follow  that,  because  in  intra-uterine  rachitis,  when 
the  bones  are  still  more  yielding  than  in  rickety  children,  the 
action  of  muscles  and  other  pressures  are  sufficient  to  produce 
many  of  the  usual  rachitic  changes,  the  effect  of  the  body-weight 
is  not  a  very  important  or  even  a  predominant  influence  after 
birth. 

The  following  are  the  chief  arguments  proving  the  important 
influence  of  the  body-weight : — 

(1.)  That  all  the  changes  which  the  body- weight  and  the  resist- 
ances it  calls  out  might  be  expected  to  produce  in  the  pelvis,  do 
actually  occur  in  the  progress  from  infantile  to  adult  life.  These 
are  the  changes  already  described  (pp.  25 — 30),  namely,  relative 
increase  of  the  transverse  diameter,  rotation  of  the  sacrum  on  a 
transverse  axis,  with  corresponding  increase  of  its  curvature  in 
antero-posterior  section  and  diminution  of  the  sacro -vertebral 
angle,  flattening  of  the  sacral  curve  in  transverse  section,  sinking 
of  the  sacrum  deeper  between  the  ilia  in  the  direction  of  the 
coccyx,  separation  of  the  tubera  ischii,  widening  of  the  pubic 
arch,  and  general  relative  increase  of  the  pelvic  outlet.  Fehling, 
indeed,  contends  that  conclusions  drawn  from  dried  foetal  pelves  are 
unsafe,  on  account  of  the  change  of  shape  which  occurs  in  drying. 
He  declares  that  the  transverse  expansion  of  the  brim  is  present 


Anatomy  of  the  Pelvis.  33 

even  at  the  third  month  of  foetal  life,  and  that  sexual  differences 
are  plainly  seen  even  at  the  fifth  month.  Hence  he  argues  that 
the  traction  of  the  ilio-sacral  ligaments  is  far  less  important  than 
Matthews  Duncan  supposed,  and  that  the  transverse  expansion  of 
the  foetal  pelvis  dejDends  upon  original  growth.  Professor  Thomson 
also  concludes  that  the  ratio  of  the  transverse  to  the  conjugate  is 
nearly  the  same  in  the  foetus  as  in  the  adult.  It  may  be  allowed 
that  Matthews  Duncan  under-estimated  the  relative  influence  of 
the  process  of  development.  But  the  facts  shown  by  Thomson  do 
not  controvert  the  view  of  Matthews  Duncan  with  regard  to  the 
leverage  action  of  the  innominate  bone  under  the  influence  of  the 
body-weight,  but  rather  confirm  it.  For  since  the  relative  wddth 
of  the  sacrum  becomes  diminished  from  foetal  to  adult  life,  the 
adult  pelvis  should  be  narrower  transversely  than  the  foetal  so  far 
as  regards  the  effect  of  growth  ;  and,  in  the  bedridden  pelvis  (see 
Chapter  XXX.),  this  is  found  to  be  actually  the  case.  But  Thomson's 
measurements  give  an  average  ratio  of  transverse  to  conjugate  in 
the  foetus  of  only  1*18  as  compared  with  1*27  (Verneau)  in  the 
adult.  Thus  actual  widening  takes  place  normally,  though  less 
than  was  formerly  supposed. 

(2.)  That  in  rachitic  softening  of  the  bones  all  the  changes  are 
exaggerated. 

(3.)  That  in  the  various  forms  of  pelvic  deformity,  whenever  the 
pelvic  inclination,  and  therefore  also  the  component  of  the  body- 
weight  acting  in  the  plane  of  the  pelvis,  are  increased,  the  conjugate 
diameter  is  relatively  diminished  ;  whenever  these  are  diminished 
(as  in  the  kyphotic  pelvis),  the  conjugate  diameter  is  relatively 
increased. 

(4.)  That  in  the  malacosteon  pelvis  (see  Chapter  XXX.),  which 
has  originally  been  normally  developed,  and  which  is  changed  by 
mechanical  influences,  the  change  of  shape  is  obviously  due  mainly 
to  the  body-weight,  together  with  the  pressures  on  the  acetabula 
and  tubera  ischii. 

(5.)  That  the  formation  of  the  oblique  pelvis  of  Naegele,  in  which 
one  sacro-iliac  articulation  is  anchylosed  (see  Chapter  XXX.), 
can  only  be  explained  by  the  leverage  of  the  innominate  bone 
being  called  into  action  on  one  side  only,  and  so  producing  the 
usual  curvature  of  the  brim  on  that  side  only,  while  the  opposite 
side  remains  nearly  straight. 


Chaptef  IL 

OVULATION  AND  CONCEPTION. 

The  Development  of  the  Ovaries  and  Ova. — The  genital 
glands,  which  develoiD  comparatively  late,  are  situated  on  the  mesial 
aspect  of  the  Wolffian  bodies ;  the  coelomic  epithelium  in  this 
situation  proUferates  and  forms  the  so-called  germinal  epithelium, 
from  which  the  primitive  sex  cells  are  usually  considered  to  be 


s^^-<>'' 


^. 


^•?^^#R^--'|:W^ 


^-■■0-: 


Fig.  26. — Transverse  section  through  ovary,  or  ;  mesosalpinx  and 
Fallopian  tube,  ft,  to  show  Wolffian  tubules,  j:;o.  Human  foetus 
measuring  14  cm.  from  vertex  to  breech. 

derived  (Fig.  26).  Eecent  observations,  however,  have  thrown  some 
doubt  on  the  real  site  of  origin  of  these  cells,  for  in  elasmobranchii 
they  have  been  found  to  be  formed  by  the  migration  of  cells  from 
the  yolk  sac,  and  in  an  early  human  ovum  of  4*9  mm.  in  length 
Ingalls  ^  has  described  large  sex  cells  as  present  under  the  peri- 
toneum at  the  root  of  the  mesentery  in  the  region  of  the  first  five 


1  N.  W.  Ingalls,  Ai'chiv.  fiir  Mikrosp.,  1907,  Vol.  LXX.,  p.  5i7. 


Ovulation  and  Conception.  35 

trunk  segments.  If  further  investigations  should  show  these 
observations  to  be  correct,  then  the  primitive  sex  cells  must  be 
considered  as  differentiated  during  the  very  early  division  of  the 
fertilised  ovum,  as  is  the  case  in  some  of  the  lower  classes  of  the 
animal  kingdom. 

In  the  further  development  of  the  genital  gland,  the  proliferating 
germinal  epithelium,  with  the  exception  of  a  single  layer  on  the 
surface  which  persists  as  the   ei)ithelial   covering   of   the   ovary, 


\.">l  t 


'■i 

*  /,- 

^■^ 

Fig.  27. — Section  of  ovary  of  human  foetus,  14  cm.  from  vertex  to  breech, 
showing  ingrowing  columns  of  cells  (genital  cords)  and  upgrowth  of 
proliferating  stroma. 

grows  inwards  and  eventually  forms  the  primitive  ova  or  oocytes,^ 
the  follicular  epithelium,  and  most  probably  the  interstitial  cells  of 
the  ovary.  At  the  same  time  the  mesenchyme  beneath  proliferates, 
and  growing  up  between  the  columns  of  cells,  forms  the  vascular 
and  fibrous  stroma  of  the  ovary.  The  solid  ingrowing  columns  of 
cells  (genital  cords)  resemble  tubules  to  some  extent,  and  it  is  easy 
to  see  how  the  erroneous  conception  of  Pfiiiger  and  others  arose 
that  they  were  tubules  with  a  lumen. 

'  'J'he  human  ovum  before  the  ](rocess  of  maturation  and  expulsion  of  the  polar 
globules  has  J'cndered  it  ready  for  fertilisation  is,  following  the  nomenclature  intro- 
duced by  Boveri,  called  an  oocyte, 

3—2 


36  The  Practice  of   Midwifery. 

Waldeyer  describes  the  embedding  as  taking  place  by  a  reciprocal 
growth  upward  of  processes  of  the  stroma,  and  downward  of 
branching  columns  of  epithelial  cells,  which  are  eventually  cut  up 
into  clusters  (Fig.  27).  At  a  very  early  stage  some  of  the  cells  are 
conspicuous  by  their  large  size,  and  these  are  the  "primordial  ova," 
or  oocytes.     Each  cluster,  as  a  rule,  eventually  contains  one  only 


'■^'^:Wf".  -^ 


Fig.  28. — Section  of  ovary  of  foetus  of  eight  months,  showing  young 
Graafian  follicles. 

of  the  oocytes,  while  the  smaller  cells  remain  still  small,  and,  by 
numerous  divisions,  arrange  themselves  around  the  primordial 
ovum,  to  form  the  epithelium  of  the  Graafian  follicle. 

In  the  early  stages  of  development  a  cortical  zone  containing 
numerous  columns  of  cells,  and  very  little  stroma,  can  be  dis- 
tinguished from  a  central  medullary  zone  in  which  the  fibrous 
stroma  is  much  more  abundant,  and  in  which  the  genital  cords  are 
ultimately  reduced  to  a  few  epithelial  strands  in  which  ova  are  no 


Ovulation  and  Conception.  37 

longer  recognisable.  The  greater  part  of  the  ovary  is  formed  from 
the  cortical  zone.  The  researches  of  Winiwarter  ^  have  shown  that 
the  changes  occurring  in  the  cells  of  the  cortical  zone  derived  from 
the  germinal  ei^ithelium  are  of  a  very  complex  character.  Two 
main  types  of  cells  may  be  recognised,  one  with  a  large  clear  nucleus 
and  distinct  nucleolus  which  does  not  show  any  sign  of  division. 
These  are  the  young  oocytes  (Fig,  28).  The  second  type  of  cells 
contains  a  granular  nucleus  with  a  coarse  nuclear  network,  is  in 
a  state  of  active  division,  and  forms  at  first  a  single  layer  of  low 
columnar  epithelium,  and  finally  by  further  proliferation  a  many- 
celled  layer  investing  the  primordial  ovum.  The  secretion  of  the 
liquor  folliculi  leads  to  the  formation  of  a  cavity,  and  separates  the 


Fig.  29. — Section  of  adult  human  ovary.      One  follicle  just  beginning  to 
develop  is  shown,  and  four  primordial  follicles,      x  210. 

cells  immediately  surrounding  the  oocyte,  the  so-called  discus  pro- 
ligerus  or  cumulus  oophorus,  from  the  remainder  of  the  cells  lining 
the  Graafian  follicle  or  the  stratum  granulosum. 

"While  the  greater  part  of  the  actively  dividing  cells  of  the  cortical 
zone  undoubtedly  form  the  follicular  epithelium,  a  certain  number 
of  them  remain  grouped  together  in  the  spaces  between  the  follicles 
and  become  the  so-called  interstitial  cells  ^  of  the  ovary.  These 
cells  lately  have  attracted  considerable  attention  in  connection  with 
the  internal  secretion  of  the  ovary,  in  the  production  of  which  they 
are  held  by  some  writers  '^  to  play  an  important  part. 

The  formation  of  the  oocytes  from  the  young  egg  cells  proceeds 

1  v.  Winiwarter,  Archives  de  Biologic,  11)01,  Vol.  XVII.,  p.  .S3. 

2  J.  K.  Lane-Claypon,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  Vol.  XF..  No.  8.  p.  20."). 
='  Limori,  Journ.  de  Phys.  et  Path.  Gc'n.,  190-1,  Vol.  XVI. 


38  The  Practice  of   Midwifery. 

during  the  later  months  of  foetal  life,  and  usually  is  completed  at 
the  time  of  birth. 

From  the  mode  of  origin  of  the  ovary,  it  follows  that  it  is  not 
covered  by  the  peritoneum  in  the  same  sense  as  the  other  viscera. 
The  superficial  layer  of  the  original  germ  epithelium  is  not 
developed  into  ovules,  but  becomes  the  epithelial  covering  of  the 
ovary  (Fig.  30  ;  e,  Fig.  31,  p.  39).  It  is  continuous  with 
the  peritoneal  epithelium,  but  it  is  j)rismatic,  and  not  flattened. 
The   outer   fibrous    covering   of    the   ovar}^    the    so-called   tunica 


0 


,^';.A----U 


Fig.  3U. — Section  of  oA^aiy  of  woman  aged  twenty-five  years,  semi- 
diagrammatic,  showing  germinal  epithelium,  tunica  alhuginea,  stroma, 
and  Graafian  follicles. 

alhufi'inea,  is  simply  a  superficial  condensed  portion  of  the  fibrous 
stroma  of  the  organ  (Fig.  30).  It  derives  its  name  from  its  whitish 
colour,  due  to  its  vascularity  being  less  than  that  of  the  interior  of 
the  organ.  Like  the  rest  of  the  stroma,  it  contains  involuntary 
muscular  fibres,  as  well  as  connective  tissue. 

All  the  oocytes  which  are  to  be  developed  in  the  ovary  exist  in 
it  at  birth,  and  a  far  greater  number  are  present  than  are  required 
for  ovulation  throughout  the  whole  period  of  active  sexual  life. 
The  number  at  birth  has  been  estimated  as  high  as  100,000. 
A  considerable  proportion,  however,  appear  to  become  atrophied, 
and  disajjpear,   so  that  in   adult    life,   and  even   at   puberty,   the 


Ovulation  and  Conception.  39 

At   puberty,    it   is   said   that   about 


number   is   much    smaller 
30,000  remain. 


Structure  of  the  Ovary. — The  ovary  is  generally  described  as 
made  up  of  two  portions — a  cortical  zone,  containing  the  Graafian 
follicles,  and  an  internal  portion,  consisting  of  the  fibro-vascular 
stroma.  This  distinction,  however,  exists  only  in  infancy  and  early 
childhood,  and  ceases  to  be  marked  before  puberty,  although  the 
follicles  are  always  chiefly  situated  near  the  surface.  The  stroma 
is  made  up  of  wavy  connective  tissue,  mingled  with  elastic  fibres, 
and  also  a  considerable  quantity  of  involuntary  muscular  fibres. 


Fig.  31. — Section  of  a  portion  of  cat's  ovary,  e,  epithelium  ;  m  g,  membrana 
granulosa  ;  v,  vessel ;  o,  ovule  ;  s,  connective  tissue  stroma  ;  1,  medium- 
sized  follicles  ;  2,  smaller  follicles ;  3,  smallest  follicles. 

To  the  action  of  the  latter  considerable  importance  is  attached  by 
some  authorities  as  influencing  the  rupture  of  the  follicles,  and  the 
expulsion  of  the  ova.  On  section  of  an  ovary  after  puberty,  a  few 
follicles  are  seen  which  have  reached  sizes  varying  from  y^g  ^P  ^o 
^  inch,  but  the  great  majority  are  visible  only  on  microscopic 
examination. 

From  the  section  of  a  cat's  ovary  (Fig.  31)  it  will  be  seen  that 
the  primordial  follicles  lie  close  to  the  surface.  As  they  get  some- 
what larger,  they  lie  deeper  in  the  ovary,  but,  as  they  approach 
maturation,  their  superficial  part  again  approaches  the  surface  until 
the  covering  gives  way.  The  explanation  is  that,  the  superficial 
layer  of  the  ovary  being  denser  than   the  subjacent  stroma  (see 


40  The  Practice  of   Midwifery. 

Fig.  30),  the  enlarging  follicle  at  first  goes  inward  in  the  direction 
of  least  resistance.  When  it  has  got  so  large  that  it  can  go  no 
further  inward,  it  begins  to  stretch  and  thin  the  overlying  layer  of 
stroma,  till  at  length  it  bursts.  In  the  human  ovary  follicles  of  any- 
thing beyond  the  smallest  size  appear  less  numerous,  in  proportion 
to  the  stroma,  than  in  that  of  the  cat. 

The  Graafian  follicle,  when  approaching  maturity,  is  generally 
described  as  having  two  coverings.  Of  these,  the  innermost  is  of 
most  importance.  The  external  connective  tissue  covering,  the  theca 
foUiculi,  has  two  layers— an  outer,  the  tunica  externa,  or  fibrosa, 


Fig.  82. — Wall  of  Graatian  follicle,  showing   the   two   layers   of    the   theca 

folliculi. 

and  an  inner,  the  tunica  interna  (Fig.  32).  The  tunica  externa, 
consisting  of  highly  vascularised  connective  tissue  arranged  con- 
centrically round  the  follicle,  is  formed  from  the  stroma  of  the 
ovary  and  the  vessels  supplying  the  follicle.  The  tunica  interna, 
more  cellular  in  structure,  is  made  up  of  large  round  or  polygonal 
cells  with  well-staining  nuclei,  also  derived  from  the  cells  of  the 
stroma.  These  are  the  so-called  lutein  cells,  and  as  the  follicle 
increases  in  size  they  acquire  a  granular  appearance,  due  to  the 
accumulation  within  them  of  a  yellow  pigment,  and  ultimately  play 
an  important  part  in  the  development  of  the  corpus  luteum.  The 
innermost  layer  is  an  epithelial  lining,  called  the  membrana 
granulosa,  and  is  made  up  of  cubical  cells  of  granular  appearance. 


Ovulation  and  Conception. 


41 


several  layers  deep  (Figs.  32,  33).  At  one  spot  on  the  circum- 
ference there  is  a  thickening  of  the  epithelium,  forming  a  projection 
called  the  discus  proligerus  or  cumulus  oophorus,  and  in  this  the 
ovum  is  embedded  (Fig.  33).  At  an  early  stage  of  the  development 
of  the  follicle  its  cavity  is  entirely  filled  by  the  oocyte  surrounded 
by  several  layers  of  polygonal  or  cuboidal  cells,  the  nuclei  of  which 
stain  well.  As  the  follicle  approaches  maturity  a  relatively  large 
space  forms,  filled  with  clear  fluid  called  the  liquor  folliculi,  which 
is  believed  to  be  formed  by  degenerative  processes  occurring  in  the 


M\ 


^^j. 


Fig.  33. — Graafian  follicle,  showing  membrana  granulosa,  discus  proligerus, 
tunica  interna,  and  tunica  externa. 


cells  of  the  membrana  granulosa,  or  by  transudation  from  the 
surrounding  vessels. 

The  ovarian  ovum,  or  oocyte,  may  be  regarded  as  a  greatly 
developed  cell,  having  its  nucleus  and  nucleolus.  Immediately 
before  its  discharge  from  the  Graafian  follicle  it  measures  about 
•22  mm.  to  '32  mm.  in  diameter. 

Its  outer  covering,  corresponding  to  the  cell-wall,  is  a  tough, 
elastic,  and  transparent  membrane,  called  the  zona  ijellucida.  In 
some  of  the  lower  animals  there  exist  openings,  to  allow  the  access 
of  the  spermatozoa,  either  in  the  form  of  a  single  aperture,  the 
micropijle,  or  of  numerous  minute  pores. 

Under  the  microscope  a  faint  radial  striation  can  often  be  detected 
in  this  membrane,  and  on  this  account  it  is  usually  termed  the 
zona  radiata,  or  the  striated  membrane  of  the  ovum. 

These  striae  are  l^elieved  to  l)e  minute  pores,    and  it  has  been 


42  The  Practice  of  Midwifery. 

shown  by  Heape^  and  others  that  they  are  occupied  by  processes  of 
the  cells  of  the  corona  radiata,  the  innermost  layers  of  cells  of  the 
discus  proligerus  immediately  surrounding  the  ovum. 

Within  the  zona  radiata  a  second  thin  membrane  has  been 
described,  but  its  existence  is  doubtful,  and  the  appearance  may  be 
due  to  the  fact  that  the  processes  of  the  cells  of  the  corona  radiata 
are  continued  through  the  zona  into  the  protoplasm  of  the  ovum. 

The  cavity  enclosed  by  the  zona  radiata  is  filled  by  the  egg 
protoplasm,  which  contains  a  number  of  granules  of  different  sizes. 


Fig.  34. — Human  ovum,  showing  the  corona  radiata,  the  zona  radiata,  the 
protoplasm  and  deutoplasm,  the  germinal  vesicle  and  germinal  spot.  (Van 
der  Stricht.  Bull,  de  I'Acad.  de  Med.  de  Belgique,  1905,  19,  p.  303.) 

the  yolk  or  deutoplasm  (Fig.  34).  The  larger  granules  are  found  in 
the  centre  of  the  egg,  while  the  smaller  granules  are  arranged  round 
the  periphery.  Embedded  in  the  protoplasm,  usually  somewhat 
excentrically,  is  the  germinal  vesicle,  about  30  /x  to  45  /a  in 
diameter,  corresponding  to  the  nucleus  of  the  cell.  It  is  spherical 
in  outline,  consists  of  a  nuclear  membrane  enclosing  a  clear  matrix, 
and  contains  one  or  more  nucleoli,  the  largest  of  which  is  termed 
the  germinal  spot. 

Occasionally  two  germinal  vesicles  are  present  in  the  ovum,  and 
two  or  three  ova  may  at  times  be  found  in  a  single  follicle. 

1  Heape,  Quart.  Journ.  Micros.  Science,  1886,  Vol.  XXVI.,  p.  157. 


Ovulation  and  Conception.  43 

Relation  of  Menstruation  to  Ovulation. 

Menstruation  consists  of  a  discharge  of  blood  from  the  mucous 
membrane  of  the  body  of  the  uterus,  accompanied  by  an  increased 
secretion  from  the  mucous  glands  of  the  uterus  and  vulva.  The 
discharge  recurs  at  intervals  which  normally  are  generally  from 
twenty-eight  to  thirty  days.  The  intervals,  however,  vary  some- 
what in  different  women,  and  in  some  cases,  without  any  departure 
from  health,  they  are  habitually  as  short  as  three  weeks  or  as  long 
as  six  weeks.  The  degree  of  regularity  of  the  intervals  also  varies 
in  different  persons,  but  any  great  irregularity  generally  implies 
some  deviation  from  perfect  health.  The  intervals  are  to  be 
reckoned  not  from  the  end  of  the  period,  but  from  the  beginning 
of  the  one  to  the  beginning  of  the  next. 

The  duration  of  the  discharge  and  its  amount  also  vary  greatly, 
both  in  different  women,  and  in  the  same  woman  at  different  times 
and  in  different  circumstances.  From  three  to  four  days  is  the 
commonest  duration  of  the  flow  in  this  country,  but  it  may  last 
only  a  few  hours,  or  as  long  as  eight  days,  without  disturbance  of 
health.  It  generally  commences  gradually,  becomes  most  profuse 
about  the  second  or  third  day,  and  then  gradually  diminishes. 
The  total  amount  of  blood  normally  lost  at  the  period  is  variously 
estimated  at  from  two  to  six  ounces,  and  about  three  ounces  may 
probably  be  taken  as  the  average.  The  quantity  is  greater  in  hot 
climates  than  in  cold  ;  and  it  is  also  increased  by  luxurious  living, 
and  by  premature  or  undue  mental  stimulation. 

Character  of  the  Menstrual  Fluid. — The  menstrual  blood  has 
usually  the  peculiarity  of  not  coagulating.  This  depends  upon  its 
becoming  mixed  with  mucus.  Thus,  when  menstrual  fluid  is 
retained  in  consequence  of  an  imperforate  hymen  or  congenital 
septum,  it  becomes  a  thick  treacly  fluid  without  clots.  If  the 
amount  of  blood  be  excessive,  or  if  it  be  poured  out  suddenly,  clots 
are  formed,  the  relative  proportion  of  mucus  l>eing  then  insufficient 
to  prevent  coagulation. 

On  microscopic  examination  of  the  menstrual  fluid,  besides  blood 
and  mucous  corpuscles,  and  vaginal  epithelium,  there  is  to  be  seen 
epithelium  from  the  cavity  of  the  uterus.  Not  uncommonly,  also, 
shreds  can  be  detected,  showing  the  structure  of  the  mucous  mem- 
brane of  the  body  of  the  uterus.  Sometimes  these  form  thin  flat 
pieces,  in  which  the  openings  of  the  uterine  glands,  and  occasionally 
even  the  epithelial  lining  of  those  glands,  may  be  seen. 

The  menstrual  fluid  has  a  peculiar  odour,  depending  upon  the 


44  The  Practice  of  Midwifery. 

mucous  secretion  mixed  with  it,  and  analogous  in  some  measure  to 
that  which  exists  in  animals  during  the  period  of  rut.  The  fluid 
very  readily  decomposes,  but  apart  from  decomposition,  there  is  no 
foundation  for  the  popular  prejudice  that  it  has  especially  injurious 
properties.  The  relative  proportion  of  blood  to  mucus  in  the 
menstrual  fluid  increases  from  its  commencement  up  to  its  maximum, 
and  gradually  diminishes  again  towards  its  close. 

Source  of  the  Menstrual  Blood. — It  is  now  universally  agreed 
that  the  source  of  the  menstrual  blood  is  the  mucous  membrane 
lining  the  body  of  the  uterus,  and  this  alone.  It  does  sometimes 
happen  that,  under  the  influence  of  the  active  arterial  flux  caused 
by  the  menstrual  nisus,  hasmorrhage  takes  place  from  the  cervix 
uteri,  or  even  from  the  vagina  or  vulva,  when  there  exists  an  erosion, 
ulcer,  or  recent  wound  in  these  regions.  Again,  in  cases  of  reten- 
tion of  menstrual  fluid  from  atresia  of  the  vagina  or  cervix  uteri, 
the  Fallopian  tubes  have  sometimes  been  found  distended  with 
blood  as  well  as  the  uterus,  but  shut  off  by  a  constriction  from  the 
uterine  cavity.  In  these  instances  the  mucous  membrane  of  the 
Fallopian  tubes  must  have  poured  out  blood  during  menstruation. 
All  these  cases,  however,  are  only  instances  of  an  abnormal  condi- 
tion, and  in  normal  menstruation,  although  the  Fallopian  tubes 
take  part  in  the  general  hypersemia  of  the  genital  organs,  yet  no 
hsemorrhage  occurs  from  their  mucous  membrane. 

With  regard  to  the  exact  mechanism  of  the  escape  of  the  blood 
from  the  mucous  membrane,  there  is  not  yet  so  much  agreement. 
Theories  have  been  held  that  the  blood  transudes  through  the  walls 
of  unbroken  capillaries  under  tbe  influence  of  congestion,  or  that 
permanent  openings  exist  from  the  vessels  into  the  uterine  glands, 
closed  merely  by  muscular  contraction  through  the  intermenstrual 
intervals  ;  and  these  theories  have  not  yet  been  entirely  abandoned. 
But  the  evidence  largely  preponderates  in  favour  of  the  view  of 
which  Pouchet  and  Tyler  Smith  were  the  first  chief  supporters, 
namely,  that  at  each  menstrual  period  more  or  less  of  the  surface 
of  the  mucous  membrane  is  broken  up  and  cast  off",  allowing  the 
blood  to  escape  through  the  torn  capillaries.  There  is  no  doubt 
that,  in  a  special  morbid  condition,  the  so-called  "  membranous 
dysmenorrhoea,"  a  considerable  thickness  of  mucous  membrane  is 
separated  and  thrown  off  in  one  or  several  pieces.  It  is  also  a  fact, 
although  not  so  universally  recognised,  that  a  certain  approxima- 
tion towards  this  condition  is  quite  common,  especially  in  women 
who  suffer  pain  in  menstruation  from  the  first  outset  of  that 
function.      In  such  cases  a  careful  examination  of  the  menstrual 


Ovulation  and  Conception.  45 

fluid  frequently  reveals  shreds  which  microscopic  examination 
shows  to  belong  to  the  body  of  the  uterus,  and  to  contain  either  the 
apertures  for  the  glands,  or  sometimes  the  entire  structure  of  the 
glands,  including  the  epithelial  lining. 

If  the  uterus  of  women  who  have  died  within  about  ten  days 
after  the  cessation  of  the  iast  menstrual  period  be  examined,  the 
mucous  membrane  is  found  to  be  generally  not  more  than  2^7  inch 
to  Jo  inch  in  thickness,  and  it  shows  no  very  sharp  line  of  demarca- 
tion from  the  muscular  wall  beneath,  the  extremities  of  many  of 
the  glands  dipping  into  the  muscular  layer.  If  death  take  place 
during  a  period  of  amenorrhoea,  the  condition  is  very  similar.  If, 
however,  a  woman  who  menstruates  normally  has  died  very  shortly 
before  the  expected  onset  of  a  period,  the  thickness  of  the  mucous 
membrane  is  much  increased  by  distension  of  the  vessels  and 
serous  exudation  into  the  stroma,  being  often  as  much  as  ^  inch  at 
its  thickest  part.  The  stroma  cells  swell  up  and  become  more 
evident,  but  their  nuclei  stain  less  deeply.  The  epithelium  of  the 
surface  and  of  the  glands  is  swollen ;  the  cilia  become  ill  defined  ; 
the  glands  are  enlarged  and  in  parts  dilated.  The  capillary  net- 
work near  the  surface  becomes  much  more  evident,  and  the  blood 
spaces  are  engorged  with  blood,  while  numerous  leucocytes  are  to 
be  seen  in  the  neighbourhood  of  the  vessels  and  near  the  surface. 
There  is  some  differentiation  into  a  compact  and  spongy  layer, 
owing  to  the  fact  that  the  stroma  cells  become  most  swollen  near 
the  surface  of  the  mucous  membrane. 

In  cases  of  death  during  menstruation,  more  or  less  of  the 
mucous  membrane  has  been  found  disintegrated  and  removed ; 
but  on  this  point  the  evidence  is  at  present  conflicting.  The 
difficulty  of  settling  the  question  arises  from  the  fact  that  fatal 
diseases  may  gravely  alter  the  normal  menstrual  changes,  a  uterine 
hsemorrhage  which  is  not  true  menstruation  often  occurring  shortly 
before  death.  The  softened  mucous  membrane  also  easily  under- 
goes jwst-mortem  dissolution.  Tyler  Smith  believed  that  the 
mucous  membrane  was  completely  exfoliated,  and  described  and 
figured  the  uterus  of  a  woman  who  died  during  menstruation,  in 
which  the  mucous  membrane  ceased  abruptly  at  the  os  internum, 
that  of  the  body  of  the  uterus  l)eing  entirely  wanting.  Sir  John 
Williams  also  holds  that  the  whole  of  the  tissues  generally  regarded 
as  mucous  membrane  is  disintegrated  and  cast  off.  He  described 
four  cases  in  which  he  found  the  mucous  membrane  entirely  absent 
over  part,  or  the  whole,  of  the  body  of  the  uterus,  after  death 
during  menstruation,  but  all  these  were  cases  of  death  from  acute 
febrile  diseases. 


46  The  Practice  of   Midwifery. 

This  view  has  not  been  supported  by  any  other  histologists,  and 
was  probably  based  upon  imperfect  methods  of  section-cutting. 
Leopold  records,  amongst  others,  two  cases  of  sudden  death  by 
accident  during  menstruation,  and  concludes  that  only  a  very 
superficial  layer  of  the  mucous  membrane  is  thrown  off.  Engel- 
mann  denies  even  so  much  exfoliation  as  this.  Spiegelberg 
extirpated  an  inverted  uterus  during  menstruation,  and  found 
the  mucous  membrane  intact,  except  a  partial  loss  of  the  most 
superficial  epithelial  layer.  Wyder  records  two  cases  of  death 
from  accident  on  the  fourth  and  eighth  days  respectively  from  the 
commencement  of  menstruation.  He  finds  a  notable  loss  of 
thickness  of  the  mucous  membrane  during  menstruation,  but  no 
disintegration  of  its  whole  thickness.  The  majority  of  modern 
observers,  especially  Moericke,  De  Sin^ty,  Lohlein,  and  Gebhard, 
hold  that  the  exfoliation  of  mucous  membrane  is  only  superficial, 
and  that  not  even  the  whole  of  the  surface  epithelium  is  necessarily 
cast  off ;  but  V.  Kahlden  and  Christ  believe  that  the  destruction  is 
always  considerable. 

According  to  Heape,  monkeys  in  India  menstruate  about  every 
month,  in  a  very  similar  way  to  women.  In  observations  made 
esjDecially  upon  Semnopithecus  entellus,  Heape  finds  exfoliation  of 
the  superficial  part  of  the  mucous  membrane,  by  which  the  vessels 
are  laid  open.  At  the  onset  of  menstruation,  he  finds  degeneration 
of  the  superficial  layer  of  the  mucous  membrane.  In  this  layer, 
congested  capillaries  break  down  with  extravasation,  and  red  and 
white  cells  are  swept  into  the  stroma.  The  extravasated  blood 
collects  in  lacuna  in  the  stroma,  and  these  lacunae,  extending  and 
dissecting,  lift  the  epithelium.  All  the  epithelium,  portions  of 
glands,  and  sometimes  whole  glands  are  swept  away.  The  inner 
surface  of  the  uterus  appears  ragged,  with  masses  of  blood  here  and 
there,  but  the  deep  layers  of  the  stroma  are  wholly  intact. 

In  a  case  of  sudden  death  of  a  woman  by  drowning  ten  days 
from  the  beginning  and  seven  from  the  end  of  a  period,  I  found  a 
fully  developed  mucous  membrane,  ^inch  thick — a  thickness  which 
seems  to  be  too  great  to  be  consistent  with  the  whole  thickness  of 
mucous  membrane  having  been  thrown  off  in  menstruation.  I  have 
also  snipped  out  a  small  portion  of  the  surface  of  an  inverted 
uterus  at  the  end  of  menstruation,  and  found  a  thickness  of  mucous 
membrane  as  much  as  j\j  inch  existing.  The  evidence,  therefore, 
is  on  the  whole  in  favour  of  the  view  that  the  menstrual  bleeding 
is  due  to  a  disintegration  of  the  surface  of  the  mucous  membrane 
reaching  to  a  proportion  of  its  thickness,  probably  varying  in 
different  women,  but  not  to  its  whole  depth.     On  this  view,  in 


Ovulation  and  Conception.  47 

those  cases  in  which  either  small  shreds,  or  more  complete  pieces, 
of  membrane  are  found  in  the  menstrual  discharge,  there  is  an 
undue  fibrillation  or  toughness  of  the  exfoliated  portion,  so  that 
the  disintegration  is  less  complete  than  it  should  be.  The  cause 
of  the  normal  disintegration  is  probably  to  be  found,  partly  in 
some  degenerative  change  in  the  tissues,  partly  in  extreme  pressure 
in  the  small  vessels  of  the  mucous  membrane.     Fatty  degeneration, 


.  U  idt'T' 


Fig.  35. — Composite  drawing  of  mucous  membrane  of  uterus  removed  by 
hysterectomy  on  first  day  of  menstruation,  hi,  extravasated  blood  ; 
atr,  stroma  ;  gl,  gland  ;  Is.  str,  isolated  portions  of  broken-up  stroma. 

preceding  any  actual  exfoliation,  is  described  by  Sir  John  Williams, 
but  its  existence  is  denied  by  Leopold  and  Wyder.^ 

1  For  evidence  as  to  the  changes  of  the  mucous  membrane  in  menstruation,  reference 
may  be  made  to  the  following  papers  : — Sir  John  Williams, "  On  the  Structure  of  the 
Mucous  Membrane  of  the  Uterus  and  its  Periodical  Changes,"  Obstet.  Journ.  Great 
Britain,  Vols.  II.,  V.  ;  Leopold,  "  Die  Uterusschleimbaut  und  die  Menstruation,"  Archiv. 
fiir  Gynalcologie,  Bd.  XI.,  1877,  p.  Ill  ;  Wyder,  "Beitrage  fllr  Normalen  und  Patholo- 
gischen  Ilistologie  der  Menschlichen  Uterusschleimbaut,"  7&/<Z.,  Bd.  XIII.,  1878,  p.  1.5  ; 
Bland  Sutton,  Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes,  p.  7  ;  Heape, 
"The  Menstruation  of  Semnopithecus  entellus,"  Phil.  Trans.,  London,  1894  and  1897  ; 
"  Menstruation  and  Ovulation  of  Monkeys  and  the  Human  Female,"  Obst.  Soc.  Lend. 
Trans.,  Vol.  XL.,  1898,  p.  101  ;  De  Sincty,  "Eecherches  sur  la  Muqueuse  Uterine  pendant 
la  Menstruation,"  Gaz.  Mcid.  de  Paris,  No.  7, 1881  ;  Lohleiii,  "  Das  Verhalten  der  Uterus- 
schleimbaut wiibrend  der  Menstruation,"  Gynak.  Tagesfragen,  H.  2,  No.  6  ;  Moericke, 
"  Die  Utcrus.schleimhaut  in  Verscheiden  Altersperioden  und  zur  Zeit  der  Menstruation," 
Zeitschr.  f.  Geb.  u.  Gyn.  VII.  84—187,1882;  Gebhard,  "  Die  Menstruation,"  Vcit's 
Handbuch  der  Gyn.  TArA,  1893;  Mandl,  "  Beitrag  zur  Frage  des  Verhaltens  der 
Uterusmucosa  wahrend  der  Menstruation,"  Arch.  f.  Gyn.  Lll.  .5.57 — .578,  1896  ;  Christ, 


48  The  Practice  of  Midwifery. 

In  Fig.  35,  p.  47,  is  shown  a  section  of  the  superficial  part  of  the 
mucous  membrane  of  a  uterus  removed  by  hysterectomy  a  few  hours 
after  the  commencement  of  menstruation.  In  the  menstruating 
uterus  there  is  marked  extravasation  of  blood  into  the  stroma, 
partly  the  result  of  diapedesis  and  partly  the  result  of  actual 
rupture  of  the  walls  of  the  capillary  vessels  (Fig.  35).  The  blood 
makes  its  way  towards  the  free  surface  of  the  mucous  membrane 
and  either  forms  small  sub-epithelial  collections  of  blood  (the  sub- 
epithelial hfematomata  of  Gebhard),  which  ultimately  burst  into 
the  uterine  cavity,  or  the  corpuscles  escape  at  many  points  through 
small  openings  between  the  epithelial  cells  of  the  surface  mucous 
membrane,  at  which  before  the  hciemorrhage  occurs,  as  Tussenbrock^ 
and  Mendes  de  Leon  have  pointed  out,  numerous  leucocytes  have 
previousl}^  escaped,  giving  rise  to  the  ante-menstrual  leucorrhoea 
which  normally  occurs. 

Haemorrhages  also  occur  into  the  lumen  of  the  glands,  and 
portions  of  the  mucous  membrane  are  thrown  off,  in  some  places 
consisting  merely  of  the  epithelium,  in  others  of  small  fragments 
of  the  stroma  and  glands. 

The  regeneration  of  the  tissues  after  menstruation  ceases  is 
carried  out  by  the  formation  of  new  cells  from  the  epithelium  of 
the  surface  and  of  the  glands,  and  also  by  the  formation  of  new 
stroma  cells.  This  process  is  attended  by  well-marked  mitosis,  and 
occurs  in  all  parts  of  the  mucous  membrane  near  the  surface. 

Theory  of  Menstruation. — When  the  ovaries  are  congenitally 
entirely  absent,  no  menstruation  occurs,  and  the  same  result 
follows  if  the  ovaries  are  removed  in  early  life.  Examples  of  this 
are  said  to  exist,  or  to  have  existed,  in  the  hedjeras,  or  guards  to 
the  harem,  in  certain  parts  of  Asia.  A  stimulus  originating  in  the 
ovaries  is  therefore  essential  to  the  first  establishment  of  menstrua- 
tion. It  is  also  essential,  in  most  cases,  for  its  continuance.  By 
the  removal  of  both  ovaries,  whether  enlarged  by  tinnour  or  not, 
an  artificial  menopause  is  brought  on  as  a  general  rule.  Not  very 
unfrequently,  it  is  true,  either  irregular  uterine  haemorrhage,  or  even 
perfectly  regular  menstruation,  continues  after  the  operation.  In 
most  instances,  however,  this  is  due  to  some  small  fragment  of 
ovarian  stroma,  or  a  supplementary  ovary  having  been  left  behind. 
Thus,  in  one  case  of  oophorectomy,  under  the  care  of  Dr.  Battey, 

"  Das  Verhalten  der  Uterusschleimhaut  wahrend  der  Menstruation."  D.  I.  Giessen, 
1897  ;  V.  Kahlden,  "  Beitrage  flir  Geb.  und  Gjnak.,"  Hegar's  Festschrift,  1889  ; 
Macgregor,  Pathology  of  the  Endometium,  1905. 

1  Tnssenbrock  and  Mendes  de  Leon,  Arch.  f.  Gynak.,  Hft.   3,   1894,  Vol.   XLVII., 
p.  497. 


Ovulation  and  Conception.  49 

not  only  menstruation  but  pregnancy  occurred  after  the  operation, 
though  only  a  minute  fragment  of  stroma  was  left,  and  the  same 
result  has  happened  in  other  similar  cases. •■■ 

It  is  now  generally  believed  that  the  influence  of  the  ovaries 
upon  menstruation  and  upon  the  development  and  nutrition  of  the 
body  generally  is  due  to  an  internal  secretion  rather  than  to  any 
reflex  influence  transmitted  through  the  nerves.  This  appears  to 
be  established  by  the  fact  that  it  has  been  found,  in  experiments 
upon  animals,  that  atrophy  of  the  uterus  and  vagina  rapidly 
follows  upon  removal  of  the  ovaries,  whereas  this  does  not  occur  if 
the  ovaries  are  removed  from  their  normal  position  and  transplanted 
to  other  parts  of  the  body.- 

The  researches  of  Heape  and  others  have  shown  that  the 
menstrual  cycle  is  homologous  with  the  oestrus  cycle  of  the  lower 
animals.  The  oestrus  cycle  is  divided  by  Heape  into  the  three 
periods  of  pro-oestrum,  oestrus,  and  di-oestrum.  In  the  stage  of 
pro-oestrum,  which  is  homologous  to  human  menstruation,  there  is 
congestion  of  the  genitals  and  increased  secretion  of  mucus, 
in  some  of  the  higher  animals  slightly  tinged  with  blood,  and 
accompanied  by  a  special  odour  which  attracts  the  male.  In  such 
animals  as  the  stag  spermatozoa  are  secreted  by  the  males  only  at 
the  corresponding  period.  The  pro-oestrum  is  succeeded  by  the 
oestrus,  or  the  period  of  sexual  desire,  during  which  alone  the 
female  will  receive  the  male  and  impregnation  is  possible,  and  this 
stage  is  no  doubt  usually  associated  with  ovulation.  The  analogy 
of  menstruation  with  the  stage  of  pro-oestrum  is  shown  by  the 
similarity  of  the  processes  taking  place  in  the  genital  organs,  and 
by  the  further  fact  that  sexual  feeling  in  the  human  female  is  at  its 
height  just  after  menstruation  is  over  or  at  a  period  corresponding 
to  the  stage  of  oestrus,  although  it  may  exist  also  during  the  flow 
or  just  before  its  onset.  No  doubt,  as  Teacher  and  Bryce^  point  out, 
in  the  lower  animals  ovulation  takes  place  during  oestrus  or  in  the 
late  pro-oestrum,  and  fertilisation  usually  follows  forthwith.  In  the 
human  subject,  on  the  other  hand,  a  considerable  interval  of  time 
may  elapse  between  insemination  and  ovulation  or  between 
insemination  and  fertilisation.  They  maintain,  however,  that  the 
most  favourable  condition  for  successful  impregnation  is  the  occur- 
rence  of    insemination    and    ovulation    simultaneously   and    the 

1  li.  Battey,  "  Oophorectomy,"  Transactions  of  International  Medical  Congress, 
1881. 

'^  Knauer,  "Die  Ovarientransplantation,"  Arch.  f.  Gynak.,  LX.,  p.  322,  1900; 
Halban.  "  Ueber  den  Einfluss  der  Ovarien  auf  die  Entwickelung  des  Genitales," 
Monats.  fiir  Geburts  und  Gyniik.,  Bd.  XII.,  p.  497,  1900;  Heape,  loc.  c'lt. 

^  The  pjarly  Development  and  Embryology  of  the  Human  Ovum,  1908. 

M,  4 


50  The  Practice  of   Midwifery. 

occurrence    of    fertilisation    immediately    the    male   and    female 
elements  meet  as  in  the  lower  animals. 

In  most  cases  the  first  menstruation  is  believed  to  mark,  or 
shortly  to  follow,  the  first  ripening  of  ova.  In  some  instances, 
however,  ovulation  occurs  in  girls  who  have  never  menstruated,  as 
is  proved  by  the  fact  that  pregnancy  has  sometimes  occurred  before 
there  has  been  any  appearance  of  the  menstrual  flow.  It  is  the 
general  rule  that,  in  connection  with  each  menstrual  period,  one  or 
more  ova  are  discharged,  but  exceptions  to  this  rule  are  not 
uncommon.  The  occurrence  of  ovulation  without  menstruation  is 
proved  by  pregnancy  taking  place  during  periods  of  amenorrhoea, 
and  by  occasional  cases  of  oophorectomy  performed  about  the 
middle  of  an  intermenstrual  interval,  in  which  a  follicle  is  found 
apparently  just  ruptured.  That  of  menstruation  without  ovulation 
is  shown  by  instances  in  which  no  sign  of  recent  or  impending 
rupture  of  a  follicle  has  been  found  when  death  has  taken  place,  or 
oophorectomy  has  been  performed,  just  after,  or  during,  normal 
menstruation. 

Cycle  of  Menstrual  Changes. — The  effects  of  menstruation  are 
not  confined  to  the  uterus  and  ovaries,  nor  to  the  time  of  the  men- 
strual period,  but  there  is  a  monthly  cycle  of  nutrition  influencing  in 
some  degree  the  whole  organism.  In  susceptible  women  there  is 
often,  for  some  days  before  the  flow,  a  fulness  with  tenderness  of 
the  breasts,  which  begins  to  pass  away  as  soon  as  the  flow  com- 
mences. This  condition  appears  to  indicate  a  tendency  to 
commencing  development  in  the  breasts,  coincident  with  the 
monthly  development  of  the  uterine  mucous  membrane.  Sphyg- 
mographic  observations  have  shown  that  the  arterial  tension  is 
generally  somewhat  raised  above  the  average  before  the  flow,  and 
sinks  to  a  level  rather  below  the  average  during,  and  shortly  after, 
the  flow.  According  to  Dr.  Stephenson's  observations,  both  the 
temperature  of  the  body  and  the  excretion  of  urea  also  follow  a 
monthly  cycle.  The  curve  of  temperature  is  above  the  mean  for 
about  half  the  month,  rising  to  about  half  a  degree  above  the  mean 
line ;  it  crosses  and  falls  below  that  line  about,  or  shortly  before, 
the  time  of  onset  of  menstruation,  and  sinks  to  a  similar  depth 
below  it  for  about  a  similar  interval.  The  curve  indicating  the 
excretion  of  urea  follows  a  very  similar  course.  There  are  thus 
general  signs  of  increased  activity  of  nutritive  changes  conincident 
with  the  time  of  development  of  the  uterine  mucous  membrane. 

The  cause  of  the  monthly  periodicity  cannot  be  explained,  but  it 
probably   lies  in   the   nervous  centres  rather  than  in  the  ovaries. 


Ovulation  and  Conception.  51 

This  view  appears  to  be  confirmed  by  the  effect  which  a  nervous 
shock,  such  as  a  fright,  or  excessive  muscular  exertion,  often  has  in 
bringing  on  menstruation  prematurely.  The  commencing  matura- 
tion of  the  Graafian  follicle  is  probably  the  consequence  rather  than 
the  cause  of  the  same  arterial  afflux  of  blood  to  the  uterus  and 
ovaries  which  causes  the  development'of  the  uterine  mucous  mem- 
brane. As  the  maturation  proceeds,  a  reflex  stimulus  from  the 
ovarian  nerves  increases  the  afflux  of  blood  until  menstruation  is 
determined.  In  morbid  conditions  of  the  ovary,  when  maturation 
of  follicles  is  interfered  with,  or  hastened  by  undue  congestion, 
menstruation  is  aj)t  to  be  irregular,  or  its  rhythm  to  be  altered. 

Pfliiger's  theory  that  menstruation  was  due  to  the  reflex  irritation 
of  the  nerves  of  the  ovary  by  the  pressure  of  the  growing  Graafian 
follicle  has  received  some  support  from  the  experiments  of  Strass- 
mann,^  who  has  succeeded  by  the  injection  of  various  substances, 
such  as  gelatine,  into  the  stroma  of  the  ovary,  in  inducing  the 
signs  of  "  heat "  and  swelling  and  hyperemia  of  the  mucous  mem- 
brane of  the  uterus  in  bitches. 

That  the  afflux  of  blood,  however,  precedes  the  onset  of  menstrua- 
tion is  illustrated  by  what  is  observed  in  the  case  of  soft  fibroid 
tumours.  Such  tumours  often  vary  perceptibly  in  size  during  the 
menstrual  cycle,  and  it  is  generally  found  that  the  greatest  size  is 
reached  a  little  before  the  onset  of  the  flow,  and  that  a  diminution 
takes  place  either  during  its  course,  or  at,  or  even  just  before,  its 
onset. 

Active  arterial  hypersemia  continues,  however,  throughout  the 
menstrual  flow,  and  is  one  of  the  factors  which  determine  the 
amount  of  blood  lost.  Thus  the  increased  activity  of  circulation 
produced  by  coitus,  or  great  muscular  exertion,  increases  the 
amount  of  flow,  and  is  apt  to  bring  it  on  again,  after  it  has  recently 
ceased.  Congestion  extends  to  the  vagina  and  vulva  throughout 
the  i)eriod,  and  if  death  occurs  during  menstruation,  the  whole 
vicinity  of  the  uterus  and  ovaries  is  found  greatly  congested.  The 
muscular  wall  of  the  uterus  is,  however,  sometimes  found  j)ale  and 
comparatively  bloodless,  and  this  condition  is  to  be  explained  by  the 
occurrence  of  muscular  contractions.  The  occasional  contractions 
which  are  manifest  to  the  hand  in  the  pregnant  uterus  take  place 
also  in  the  unimpregnated  uterus  during  menstruation,  and  probably 
at  other  times.  They  serve  to  expel  the  product  of  menstruation, 
and  close  up  the  increased  cavity  left  in  the  body  of  the  uterus  by 
the  exfoliation  of  mucous  membrane.  It  is  possible  also  that 
uterine  contraction  may  determine  the  first  rupture  of  vessels  at  the 

'  Strassmann,  Arch,  fiir  Gyniik.,  W.)(j,  Vol.  LIl.,  Hft.  1,  p.  13-t. 

4—2 


52  The  Practice  of   Midwifery. 

onset  of  menstruation  by  forcing  blood  out  of  the  muscular  wall 
into  the  mucous  membrane,  and  checking  its  return  through  the 
veins.  A  pale  condition  of  the  muscular  wall  after  death  during 
menstruation  does  not,  however,  prove  that  it  is  continuously 
bloodless  during  the  flow,  but  only  that  the  blood  has  been  squeezed 
out  of  it  by  contraction  before  death,  or  by  rigor  mortis.  With  the 
expulsive  contractions  of  the  fundus  is  associated  some  physiological 
relaxation  of  the  cervix  ;  but  any  material  dilatation  of  that  canal 
j)robably  only  occurs  when  something  bulky,  such  as  membrane, 
clot,  or  mass  of  tenacious  mucus,  has  to  be  expelled. 

Maturation  of  the  Graafian  Follicle. — Before  the  onset  of 
puberty  Graafian  follicles  are  found  only  in  the  deeper  portions  of 
the  cortex,  and  do  not  reach  the  surface  of  the  ovary.  When  the 
period  for  the  occurrence  of  the  first  ovulation  approaches,  the 
Graafian  folHcle  enlarges,  and  at  first  recedes  from,  but  afterwards 
again  approaches,  the  surface  of  the  ovary  (see  p.  40).  Under  the 
influence  of  the  hyperaemia  preceding  menstruation  there  is  great 
enlargement  and  proliferation  of  the  vessels  in  the  vascular  tunic 
of  the  follicle  which  is  nearest  to  maturity.  From  the  increased 
vascular  supjDly  follows  increased  secretion  of  the  liquor  follicuU, 
and  the  follicle  comes  to  form  a  prominence  on  the  surface  of  the 
ovary.  From  the  eflect  of  pressure  the  cells  of  the  tunica  fibrosa 
become  sej)arated  from  one  another,  and  the  tunica  interna  and  the 
tunica  albuginea  become  thinned  at  the  most  prominent  part.  At 
length  rupture  occurs,  and  the  ovum,  with  most  of  the  cells  of  the 
membrana  granulosa,  escapes  with  the  rush  of  liquor  folliculi,  aided, 
as  some  hold,  by  the  pressure  of  blood  previously  efiused  into  the 
follicle.  The  actual  ruj)ture,  which  takes  place  at  a  point  previously 
free  from  vessels,  the  so-called  stigma,  is  said  by  Clark ^  to  be  due 
to  necrotic  changes  occurring  in  this  area  of  the  wall  of  the  follicle, 
the  result  of  circulatory  changes,  and  is  facilitated  by  the  fact  that 
the  ovary  has  no  distinct  fibrous  capsule,  nor  true  peritoneal  cover- 
ing. At  the  same  time  there  is,  as  is  generally  believed,  a  kind  of 
erection  from  active  congestion  of  the  Fallopian  tube  and  its 
fimbriated  extremity,  so  that  the  latter  is  more  closely  applied  than 
usual  to  the  ovary.  The  experiments  of  Pinner  ^  and  Lode,^  who 
introduced  particles  of  colouring  matter  and  Nematode's  eggs  into 
the  peritoneal  cavity  of  dogs,  have  shown  that  the  motion  of  the 
cilia  lining  the  fimbriae  produces  a  current  of  serum  towards  the 

1  Clark,  Johns  Hopkins  Hospital  Reports,  1898,  Vol.  VII.,  p.  181. 

2  Pinner,  Arch.  f.  Anat.  u.  Phys.,  1880,  p.  241. 

8  Lode,  Arch.  f.  Gynak.,  1894,  Vol.  XLV.,p.  295. 


Ovulation  and  Conception. 


53 


m.o 


orifice  of  the  tube,  and  no  doubt  by  this  means  the  ovum  is  guided 
into  it.  Much  importance  has  been  attached  to  the  grasping  of  the 
ovary  by  the  fimbriae  of  the  tube  during  menstruation  (Fig.  36). 
The  fimbriated  extremity,  however,  is  not  large  enough  to  grasp  the 
whole  ovary,  and  the  capacity  for  erection  of  the  Fallojiian  tube 
appears  to  have  been  exaggerated.  The  current  produced  by  the 
cilia  must,  therefore,  be  of  great  consequence,  and  be  capable  of 
guiding  an  ovum  toward  the  tube,  even  when  it  has  escaped  outside 
the  grasp  of  the  fimbriae.  The  possibility  of  this  is  illustrated  by 
the  case  of  batrachians,  in  which  the  oviducts  are  situated  at  a 
distance  from  the  ovary,  and  the 
ova  are  discharged,  in  the  first 
instance,  into  the  peritoneal 
cavity.  In  this  way  also  may  be 
explained  the  cases  of  so-called 
external  migration  in  which  an 
ovum  escaped  from  one  ovary  has 
been  carried  into  the  Fallopian 
tube  of  the  opposite  side,  and 
there  arrested.^ 

The  disposition  of  the  tube  is 
also  such  that  the  action  of 
gravity  is  favourable  to  the  ovum 
reaching  its  orifice.  The  length 
of  the  tube  being  much  greater 
than  the  distance  from  the  uterus 
to  the  ovary,  the  tube  curls  over 
the  ovary  in  a  loop,  so  that  its 
outer  third  comes  to  be  outside 
and  below  the  ovary,  the  ovarian  fimbria  which  is  attached  to  the 
ovary  running  downwards  from  that  organ  to  the  orifice  of  the 
tube.  The  fimbriae,  therefore,  are  in  contact  with  the  ovary  at  or 
near  its  most  dependent  part.  It  is  probable,  however,  that  it  is 
not  very  rare  for  an  ovum  to  escape  into  the  peritoneal  cavity  and 
not  reach  the  tube. 


Fig.  36.  —  Oblique  section  through 
ovary  and  tube  in  situ,  ms,  meso- 
salpinx ;  0,  ovary ;  ^,  tube  ;  or, 
opening  of  ovarian  bursa  ;  fe,  fim- 
briated extremity ;  to,  ovarian 
bursa  ;  mo.  mesovarium.  (Bumm, 
Grundriss  der  Geburtshilfe.) 


Period  of  Rupture  of  the  Graafian  Follicle. — When  it  was 
supposed  that  the  swelling  of  the  uterine  mucous  membrane  took 
place  daring  menstruation  and  not  before  its  onset,  it  was 
believed  that  the  time  of  rupture  of  the  Graafian  follicle  was 
shortly  after  the  end  of  a  period,  and  that  an  impending  rupture 
might  be   precipitated   by   the  increased  congestion,  and  perhaps 


'  See  the  chaptei'  on  extra-uterine  fcjetation. 


54  The  Practice  of   Midwifery. 

the   contraction   of  the   muscular  fibres   in   the   ovaries,   induced 
by  coitus. 

Most  observers,  however,  believe  that  the  disappearance  of  a  fixed 
oestrus  in  the  human  female  has   resulted   in   the   severance   of 
ovulation  from  oestrus,  so  that  the  discharge  of  an  ovum  may  take 
place  at  irregular  and  uncertain  dates  throughout  the  menstrual 
cycle.     It  cannot  be  denied  that  this  is,  at  least,  a  not  infrequent 
occurrence.     From   the  apparent    analogy  between   the  supposed 
exfoliation  of  mucous  membrane  in  menstruation  and  the  exfolia- 
tion of  the  developed  mucous  membrane,    the    so-called  decidua 
vera,  at  the  end  of  pregnancy,  the  mucous  membrane  developed 
for  menstruation  has  been  called  the  menstrual  decidua.     It  has 
further  been  supposed  by  some  that  the  separation  of  this  decidua, 
and  consequent  commencement  of  menstruation,  indicates  that  the 
ovum  belonging  to  that  menstrual  period  has  not  only  escaped,  but 
has  failed  to  become  impregnated.     It  would  follow  that  the  impreg- 
nated ovum  belongs,  not  to  the  last  menstrual  period  which  occurs, 
but  to  the  first  which  fails  to  appear ;  and  that  the  duration  of 
pregnancy,  generally  reckoned  from  a  few  days  after  the  end  of 
the  last  period,  is  shorter  than  has  generally  been  supposed.     This 
is  not  supported  by  cases  of  pregnancy  from  a    single  coitus  of 
kno\Yn  date.     Moreover,  there  is  reason  to  believe  that  the  ovum 
may  take  as  much  as  nine  or  ten  days  in  passing  from  the  ovary  to 
the  uterus.     From  a  very  careful  study  of  the  data  recorded  with 
regard   to   twelve   early  human  ova,  including  one  described  by 
themselves,  the  j^oungest  human  ovum  hitherto  met  with,  of  the 
estimated  age  of   thirteen  to  fourteen  days,  Teacher  and  Bryce  ^ 
have  come  to  the  conclusion  that  the  fertilisation  of  these  ova  must 
have  taken  place  at  very  wide  intervals  during  the  month,  and  that 
ovulation   in    these   cases,   probably  corresponding   more  or  less 
closely   to  fertilisation,  must    also   have  taken  place   at  different 
intervals  during  the  month.     Further  than  this,  if  their  estimation 
of  the  ages  of    these  ova  is  correct,  then  the  embedding  of  the 
fertilised  ovum,  which  they  reckon  probably  begins  some  seven  days 
after  fertilisation,  occurs  quite    independently   of   the   menstrual 
growth  of  the  mucous  membrane  of  the  uterus,  and  may  take  place 
at  any  time  during  the  menstrual  cycle,  except  during  the  stage  of 
actual  destruction. 

They  conclude  from  their  study  of  these  early  ova  that  menstrua- 
tion is  not  a  preparation  for  the  reception  of  an  ovum  in  the  old 
sense  of  the  words,  but  that  it  represents  a  cyclical  process  which 
provides  for  the  maintenance  of  the  endometrium  in  a  suitable 

1   Early  Development  and  Imbedding  of  the  Human  Ovum.    1908. 


Ovulation  and  C.'onception. 


55 


condition  for  the  production  of  the  decidua  of  pregnancy,  and  that 
the  occurrence  of  an  ovarian  pregnancy  shows  that  the  ovum 
is  not  dependent  upon  the  development  of  a  menstrual  decidua 
for  a  suitable  nidus  in  which  to  become  embedded. 

Formation  of  the  Corpus  luteum.— Even  before  the  rupture 
of  the  Graafian  follicle  the  tunica  interna  becomes  thickened  by 
proliferation  and  enlargement  of  the  cells  composing  it,  and 
acquires  a  somewhat  granular  appearance,  due  to  the  presence  of 


Fig.  37. — Section  of  corpus  luteum  of  pregnancy,  showing  lutein  cells. 
Above  is  seen  the  central  mass  of  fibrin  ;  in  the  centre  the  mass  of  lutein 
cells,  with  radiate  partitions  of  connective  tissue  resulting  from  the 
original  convolutions  ;  below  the  stroma  of  the  ovary.  (After  Whitridge 
Williams.) 

minute  granules  of  yellow  pigment  in  the  cells.  After  its  rupture 
the  cavity  of  the  follicle  fills  up  with  blood-clot,  intermingled  with 
which  are  the  remaining  cells  of  the  membrana  granulosa.  It  was 
held  by  Coste  that  there  is  normally  no  effusion  of  blood  into  the 
follicle,  but  only  a  semi-transparent  gelatinous  material,  slightly 
tinged  with  blood-pigment.  Dalton,^  however,  found  only  one 
specimen  of  a  corpus  luteum  of  menstruation  in  which  the  central 
clot  was  absent  as  compared  with  nine  in  which  it  was  present. 
The  cells  of  the  tunica  interna,   the  so-called   lutein   cells,  now 

*  '•  Report  on   tljo  Corpus   Luteum,"  Ti'ansactions  of  the  American   GynecologicEvl 
Society,  Vol.  II. 


56  The  Practice  of   Midwifery. 

undergo  very  marked  hypertrophy,  and  their  yellow  colour  becomes 
more  conspicuous.  By  their  excessive  proliferation  within  the 
confined  area  of  the  follicle,  they  become  thrown  into  folds,  which 
have  been  compared  in  appearance  to  cerebral  convolutions.  These 
gradually  encroach  upon  the  clot  in  the  centre,  which  shrinks, 
becomes  decolorised,  and  eventually  remains  as  only  a  white 
stellate  area.  Between  the  developing  lutein  cells  a  delicate  reticular 
netw^ork  can  be  distinguished,  which  forms  a  fine  limiting  membrane 


•   "-.V  -v^-^;- •••Iv-  "4:  •:•'-.•  .-r-i^  :•:.  .:•  -.■■-/  i. 


Fig.  38. — Section  of  wall  o£  corpus  luteum,  showing  the  vascular 
connective  tissue  septa. 

separating  them  from  the  cells  of  the  membrana  granulosa,  and  in  the 
meshes  of  which  the  vascular  connective  tissue  septa  develop  (Fig.  38), 
and  form  a  series  of  partitions  dividing  up  the  masses  of  lutein 
cells,  and  giving  to  the  whole  a  somewhat  festooned  appearance. 

With  the  almost  comj)lete  disappearance  of  the  blood-clot  the 
ruptured  follicle  has  become  converted  into  a  solid  mass  of  lutein 
tissue,  divided  up  by  connective  tissue  septa,  the  whole  forming  the 
so-called  corpus  luteum,  or  yellow  body.  Soon  degenerative  changes 
make  their  appearance  in  the  lutein  cells,  and  undergoing  hyaline 


Ovulation  and  Conception.  57 

or  fatty  degeneration,  they  gradually  disappear,  and  their  place  is 
taken  by  the  newly  formed  connective  tissue,  which  grows  in  from 
the  surrounding  tissue  of  the  ovary,  and  which  ultimately  cannot 
be  distinguished  from  the  ovarian  stroma. 

At  the  height  of  its  development  the  corpus  lufceum  is  con- 
siderably larger  than  the  Graafian  follicle  from  which  it  is  formed. 
The  ultimate  absorption  of  the  lutein  cells,  especially  in  elderly 
women,  may  take  place  somewhat  imperfectly,  while  the  degenera- 
tive changes  may  extend  to  the  newly  formed  connective  tissues, 
with  the  result  that  there  is  left  in  the  stroma  of  the  ovary  a  mass 
of  hyaline  tissue  resembling  an  old  scar,  the  so-called  corpus 
fibrosum  or  corpus  albicans.  In  elderly  women  a  number  of  such 
bodies  may  be  found  in  sections  of  the  ovaries. 

The  function  of  the  corpus  luteum  appears  to  be  to  replace  the 
ruptured  follicle  by  new  connective  tissue  with  the  least  possible 
formation  of  fibrous  scar  tissue.  Clark  ^  believes  that  one  of  its 
functions  is  to  maintain  unimpaired  the  circulation  through  the 
ovarian  stroma. 

According  to  Fraenkel,  the  corpus  luteum  is  the  glandular  organ 
which  forms  the  internal  secretion  of  the  ovary,  and  is  necessary 
for  menstruation  and  pregnancy.  In  rabbits,  destruction  of  the 
corpus  luteum  prevents  the  implantation  of  the  ovum.  In  women, 
the  same  operation  almost  always  prevents  the  next  menstruation.^ 

The  origin  of  the  lutein  cells  is  a  matter  upon  which  there  is  still 

a  good  deal  of  difference  of  opinion.     Two  views  have  been  held : 

that  they  are  derived  from  the  cells  of  the  membrana  granulosa,  and 

that  they  develop  from  the  cells  of  the  tunica  interna,  and  are 

therefore  of  connective  tissue  origin.     The  majority  of  observers 

are  in  favour  of  the  latter  view,  and  there  is,  it  seems,  little  doubt  from 

the  recent  work  of  Clark,  Lockyer,^  and  others,  that  it  is  the  correct 

one.     The  fact  that  at  a  time  when  the  cells  of  the  tunica  interna 

are  showing  marked  signs  of  proliferation  those  of  the  membrana 

granulosa  are  already  exhibiting  degenerative  changes,  as  well  as 

the  fact  that  even  before  rupture  of    the  follicle  the  developing 

lutein  cells  can  be  recognised  lying  outside  the  membrana  granulosa 

and  separated  from  it  by  a  very  delicate  basement  membrane  formed 

from  the  tunica  interna,  are  strong  arguments  in  favour  of  this 

view.     The  processes  described  by  Clark  as  taking  place  in  the 

degeneration  of  follicles  in  the  interior  of  the  ovary  which  do  not 

rupture  bear  out  his  contentions  as  to  the  connective  tissue  origin 

1  Clark,  Johns  Hopkins  Hospital  Reports,  1898,  Vol.  Vn.,  p.  181. 
'^  Arch.  f.  Gyniik.,  B.  08,  H.  2, 1903. 

■■'  Cuthbert  Lockyer,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  V.,  January  and  February, 
I90r,  ;  Trans.  Ob.st,  Hoc.  London,  1905,  Vol.  XLVIT.,  p.  157, 


58 


The  Practice  of    Midwifery. 


of  the  lutein  cells.  Stevens^  has  shown  that  the  follicles  and  ova  in 
pre-menstrual  life  attain  maturit}'  by  a  well-marked  constant  series 
of  changes.  The  ova  never,  however,  attain  the  size  of  those  of  an 
adult  female,  and  the  mature  pre-menstrual  Graafian  follicle  usually 


:) 


y 


Fig.  39. — Section  of  the  human  ovary, 
showuig  a  corpus  luteuin  at  the 
third  mouth  of  gestation. 


Fig.  40. — Corpus  luteum  at  the  full 
term  of  pregnanc3\ 


measures  about  '8  to  1  mm.  in  diameter.  The  disappearance  of 
the  follicles  is  brought  about  by  a  series  of  degenerative  changes, 
during  which  the  ovum  appears  to  be  destroyed  by  phagocytic 
action  on  the  part  of  some  of  the  cells  of  the  membrana  granulosa, 

while  the  follicle  itself  becomes 
obliterated  by  the  growth  into 
it  of  a  species  of  granulation 
tissue  which  develops  from  its 
fibrous  tunic. 

When  the  ovum  has  not 
become  impregnated,  the  de- 
velopment of  the  corpus  luteum 
has  reached  its  height  after 
about  twenty  days  ;  after  this 
it  undergoes  rapid  absorption. 
The  cells  gradually  disappear, 
the  colour  is  changed  from 
3^ellow  to  a  whitish  tint,  the 
vessels  become  atrophied,  and 
eventually  there  remains  only 
the  relic  of  the  fibrous  tissue 
which  the  cells  have  formed. 
In  the  healthy  ovary  this  is 
scarcelj^  noticeable ;  when  the  ovary  is  congested  or  inflamed 
it  has  the  appearance  of  a  stellate  white  cicatrix.  The  diminu- 
tion is  already  considerably  advanced  by  the  time  the  next 
follicle  is  ready  to  rupture,  though  the  yellow  colour  is  generally 
noticeable  for  two  or  three  months.     Such  a  corpus  luteum  has 

1  Trans.  Obst.  8oc.  Lond.,  Vol.  XLV.,  p.  465.     1908. 


Fig.  41. — Diagram  of  the  formation  of  the 
corpus  luteum.  a,  the  cavity  of  the 
follicle  filled  with  blood  ;  5,  l\  the  clot 
diminishing  in  size,  while  the  epithelial 
lining  becomes  thickened  and  convo- 
luted, and  the  clot  becomes  decolorised  ; 
<7,  e,f,  completion  of  the  process.  In 
/  the  convolutions  have  coalesced  to 
form  a  yellow  mass,  the  decolorised 
remnant  of  the  clot  remaining  only  as 
a  central  stellate  cicatrix.  (After 
Dal  ton.) 


Ovulation  and  Conception.  59 

been  termed  a  false  corpus  luteum,  but  is  better  named  the  corpus 
luteum  of  menstruation.  The  corpus  luteum  of  menstruation, 
when  at  its  greatest  development,  remains,  as  a  rule,  at  the  stage 
shown  at  d,  Fig.  41.  Some  remnant  of  dark  clot  can  be  seen  near 
the  centre,  or  toward  the  surface  of  the  ovum ;  the  convolutions  of 
the  masses  of  lutein  tissue  are  distinguishable,  not  blended  into  a 
uniform  mass,  and  they  are  most  developed  in  the  part  of  the 
follicle  farthest  from  the  surface. 

If  pregnancy  occurs,  a  very  different  course  is  followed.  The 
maturation  and  rupture  of  fresh  follicles  is  then,  as  a  rule,  arrested, 
and,  according  to  Skrobansky,^  this  is  brought  about  by  the  action 
of  the  internal  secretion  of  the  corpus  luteum  of  pregnancy.  In 
consequence  of  the  hyperpemia  due  to  pregnancy  the  yellow  body 
reaches  a  much  higher  development,  and  this  develoi^ment  is  more 
protracted,  as  also  is  the  diminution.  The  greatest  height  is 
reached  about  the  third  month  ;  the  corpus  luteum  is  still  marked 
at  the  time  of  delivery,  and  does  not  entirely  disappear  for  one  or 
two  months  after.  At  the  third  month  it  is  about  two-thirds  of  an 
inch  in  length  (Fig.  39,  p.  58),  and  forms  a  manifest  prominence  on  the 
surface  of  the  ovary ;  at  the  time  of  delivery  it  still  averages  nearly 
half  an  inch  in  length  (Fig.  40,  p.  58).  The  yellow  colour  is  more 
marked ;  at  the  early  stage  the  convolutions  are  firmer  to  the 
touch,  eventually  they  blend  together  in  a  firm  mass,  their  margins 
being  only  indicated  by  bands  of  connective  tissue.  The  cells  reach 
about  g  Jq  or  even  -^^  inch  in  diameter.  The  corpus  luteum  can  be 
felt  as  a  manifest  firm  swelling  in  the  substance  of  the  ovary.  This 
is  not  generally  the  case  with  the  corpus  luteum  of  menstruation. 
In  about  one-third  of  the  cases  a  cavity  is  formed  in  the  substance 
of  the  corpus  luteum,  containing  clear  fluid,  but  more  frequently 
the  centre  is  occupied  by  the  stellate  decolorised  relic  of  the  blood- 
clot,  like  that  shown  in  Fig.  41.  The  formation  of  a  cavity  is 
ascribed  by  Dalton  to  a  separation  and  collection  of  the  serum 
belonging  to  the  original  blood-clot.  It  is  rarely,  if  ever,  observed 
in  the  corpus  luteum  of  menstruation. 

The  corpus  luteum  of  pregnancy  formerly  had  the  less  appropriate 
name  of  the  true  corpus  luteum.  The  only  structure  which  really 
deserves  the  name  of  false  corpus  luteum  is  that  which  may  be 
formed  if  a  follicle  shrinks,  and  its  wall  becomes  thickened  without 
rupture  ever  having  taken  place.  This  is  distinguished  from  a 
corpus  luteum  of  pregnancy  or  menstruation  by  the  absence  of  the 
yellow  colour,  and  by  the  fact  that  it  is  not  on  the  surface  of  the 
ovary,  nor  connected  with  a  cicatrix  on  that  surface. 

1  Skrobansky,  Arch.  f.  Mikr,  Anat.,  U)0:?,  Vol.  LXH.,  p.  GOT. 


6o  The  Practice  of   Midwifery. 

The  corpus  luteum  has  no  positive  medico-legal  value  as  a  proof 
of  pregnancy.  For  a  few  cases  have  been  recorded  in  which  the 
corpus  luteum  of  menstruation  has  appeared  to  have  all  the 
characters  usual  in  that  of  pregnancy.  This  has  generally  been  in 
instances  where  there  has  been  some  cause  for  undue  congestion, 
such  as  the  presence  of  a  fibroid  tumour  or  a  life  of  prostitution. 
On  the  other  hand,  there  have  been  cases  of  pregnancy  in  which  no 
corpus  luteum  or  none  of  distinctive  character  could  be  found. 

Commencement  and  Duration  of  Menstruation.— The  first 
menstruation  is  the  usual  sign  that  the  girl  has  become  capable 
of  conception  and  child-bearing.  It  is  believed  to  be  dependent,  as  a 
rule,  upon  the  first  ovulation,  although,  in  some  cases,  ova  are 
discharged  previous  to  any  menstruation.  According  to  Fraenkel, 
it  is  the  corpus  luteum  arising  from  ovulation  which  determines 
the  next  menstruation.  At  the  same  time  occur  the  changes, 
physical  and  mental,  which  indicate  the  arrival  at  the  age  of 
puberty.  The  body  of  the  uterus,  hitherto  small  in  relation  to 
the  cervix,  is  developed,  the  pubes  becomes  covered  with  hair, 
the  pelvis  acquires  the  typical  female  type,  and  the  breasts  are 
developed.  At  the  same  time  there  is  a  mental  change,  and  the 
girl  becomes  more  bashful  and  retiring.  Neither  the  body  of  the 
uterus,  however,  nor  the  pelvis,  at  once  reach  their  full  capacity  for 
the  discharge  of  their  functions  ;  they  do  not  generally  attain  their 
full  size  till  the  age  of  about  twenty.  The  age  at  which  menstruation 
commences  is  influenced  by  climate,  race,  and  mode  of  life.  The 
influence  of  climate  has  been  exaggerated.  It  has  generally  been 
stated  that  in  hot  climates  the  age  is  on  an  average  two  or  three 
years  earlier  than  in  cold  ;  but  modern  observations  appear  to  show 
that  there  is  no  constant  difference. 

Luxurious  living  and  early  stimulation  of  the  mental  faculties 
tend  to  bring  on  menstruation  at  an  earlier  age,  and  thus  the 
children  of  the  rich  and  dwellers  in  towns  commonly  menstruate 
earlier  than  the  poorer  classes  in  the  country.  Premature  sexual 
stimulus  has  a  similar  effect.  Feeble  health  and  poor  diet  tend  to 
retard  the  appearance  of  the  flow.  There  may  be  a  difference 
between  different  races  living  in  the  same  country,  and  among  the 
Hindoos,  whose  custom  is  for  marriage  to  be  completed  as  soon  as 
menstruation  appears,  the  age  is  peculiarly  early. 

The  age  of  appearance  of  menstruation  may  vary  from  10  to  20 
without  departure  from  health.  In  England  more  than  half  of  the 
whole  number  of  girls  first  menstruate  between  the  ages  of  14  and 
17,   and  more  than  five-sixths  between   those  of  13  and  19,  the 


Ovulation  and  Conception.  6i 

average  age  being  a  little  above  15J.  Normally  the  discharge  recurs 
at  regular  intervals,  with  the  exception  of  periods  of  pregnancy  and 
lactation,  up  to  the  menopause  or  climacteric  period,  which  is 
commonly  between  the  ages  of  40  and  50,  most  frequently  at  about 
48.  Exceptionally  menstruation  may  go  on  even  up  to  the  age  of 
00.  The  period  of  active  sexual  life  is  thus  generally  from  30  to  35 
or  40  years.  Those  who  menstruate  early  commonly  continue  to 
menstruate  late,  unless  any  pelvic  inflammation  has  led  to  atrophy 
of  the  ovaries.  Eepeated  pregnancies  tend  to  prolong  the  period  of 
sexual  activity.  Cases  occasionally  occur  in  which  true  menstruation 
begins  in  infants,  even  at  the  age  of  two  or  three,  and  continues 
regularly  from  that  time.  Such  a  condition  is  associated  with 
premature  development  of  the  breasts,  of  the  pelvis,  and  of  the 
sexual  emotions.  In  such  a  case  pregnancy  has  occurred  in  the 
ninth  year,  and  the  birth  of  a  living  child  in  the  tenth. 

Conception.— Conception  is  effected  by  union  of  the  spermatozoa 
with  the  ovum.  One  or  more  spermatozoa  penetrate  the  zona 
pellucida,  and,  on  reaching  the  yolk,  become  motionless,  and  lead 
to  certain  changes  in  the  nucleus  hereafter  to  be  described.  The 
micropyle,  or  opening  through  the  zona  pellucida  for  the  entrance 
of  spermatozoa,  though  it  exists  in  lower  animals,  as  insects  and 
fishes,  has  not  been  detected  in  mammals.  It  is  believed  that  the 
ovum  is  generally  fertilised  in  the  Fallopian  tube,  probably  for  the 
most  part  in  its  outer  half,  and  more  especially  among  its  fimbrise, 
the  folds  of  which  form  a  receptacle  in  which  the  semen  may  be 
retained  for  some  time.  This  belief  is  based  mainly  upon  experi- 
ments on  the  lower  animals,  in  which  the  spermatozoa  may  be 
found  along  the  whole  length  of  the  tube,  and  on  the  surface  of  the 
ovary,  a  few  hours  after  coitus.  Nuck  placed  a  ligature  on  one 
horn  of  the  uterus  of  a  bitch  three  days  after  coitus.  Some  time 
later  two  embryos  were  found  in  the  tube  arrested  by  the  ligature. 
Again,  if  a  bitch  be  subjected  to  coitus  just  after  the  rut  is  over, 
and  killed  a  few  hours  later,  ova  and  spermatozoa  are  found  along 
the  whole  length  of  the  tube,  but,  in  its  lower  two-thirds,  the 
spermatozoa  have  not  penetrated  the  vitelline  membrane.  This  is 
explained  by  the  change  which  takes  place  in  the  ovum  as  it  passes 
along  the  tube,  owing  to  the  addition  to  it  of  an  albuminous 
envelope.  The  phenomena  of  extra-uterine  foetation  show  that, 
in  women  also,  the  spermatozoa  may  reach  the  peritoneal  cavity. 
The  precise  mechanism  by  which  the  ascent  of  the  spermatozoa  is 
effected  is  not  positively  known.  A  great  deal  must  be  attributed 
to  their  own  power  of  motion,  since,  according  to  Henle,  they  can 


62  The  Practice  of   Midwifery. 

traverse  the  distance  of  an  inch  in  7^  minutes.  Many  cases  of 
pregnancy  with  narrow  and  unruptured  hymen  have  been  recorded, 
and  spermatozoa  have  traversed  minute  openings  in  a  vaginal 
septum.  I  have  known  a  case  of  jDregnancy  where  the  vagina 
was  contracted  up  to  a  rigid  tube,  only  ^  inch  in  diameter,  so  that 
penetration  was  totally  impossible,  while  urine  was  constantly 
trickling  through  this  tube  from  the  bladder.  In  such  instances, 
the  spermatozoa  must  have  made  their  way  by  their  own  activity 
the  whole  length  of  the  vagina,  as  well  as  of  the  uterus  and 
Fallopian  tube.  Besides  the  movements  of  the  spermatozoa  them- 
selves, the  effects  of  capillary  attraction,  and  of  suction  exerted  in 
some  way  into  the  uterus,  have  been  thought  to  have  an  influence 
on  the  ascent  of  the  spermatozoa,  and  both  of  these  may  be  im- 
portant elements  in  the  matter  in  some  cases.  Modern  physio- 
logists also  attach  importance  to  chemiotaxis,  by  which  is  meant 
the  attraction  or  repulsion  exercised  upon  organisms  by  fluids  of 
different  kinds.  In  the  majority  of  instances,  it  is  sufficient  for 
impregnation  that  semen  is  deposited  in  the  vagina  ;  but  there  is 
reason  to  believe  that,  in  women  of  ardent  temperament  at  any 
rate,  some  portion  of  it  often  ascends  almost  immediately  into  the 
cervix.  This  is  the  only  explanation  of  the  fact  that  injections  of 
cold  water,  or  various  solutions,  used  immediately  after  coitus  as  a 
prophylactic  against  pregnancy,  not  unfrequently  fail  to  secure  the 
desired  result,  though  they  are  immediately  fatal  to  the  spermatozoa 
wherever  they  reach  the  semen. 

Normally  there  is  in  coitus  as  distinct  an  orgasm  of  sensation  on 
the  j)art  of  the  woman  as  that  which  accompanies  emission  in  the 
man.  It  is  not  necessarily  associated  with  ejection  of  the  secretion 
of  any  gland,  but  is  accompanied  by  certain  muscular  actions.  The 
sexual  orgasm  is  not  necessary  to  conception,  for  the  condition  in 
which  it  is  habitually  absent,  or  what  may  be  called  sexual  frigidity, 
is  by  no  means  uncommon,  being  present  in  some  40  per  cent,  of  all 
women,  and  pregnancy  frequently  occurs  notwithstanding.  The 
occurrence  of  the  orgasm  at  the  proper  time  does,  however,  favour 
conception.  I  have  known  a  lady  who  was  married  under  twenty, 
and  lived  in  married  life  for  many  years  with  two  husbands  in 
succession.  When  she  had  passed  the  age  of  forty,  she  experienced 
the  sexual  orgasm  in  coitus  for  the  first  and  only  time  in  her  life,  and 
from  that  day  dated  her  first  and  only  pregnancy. 

It  is  difficult  to  imagine  any  mechanism  by  which  the  uterus  can 
exercise  active  suction,  although  a  suction  toward  the  abdominal 
cavity  may  sometimes  be  caused  by  sudden  expansion  of  the  chest 
during  the  sexual  orgasm,  with  closure  of  the  glottis.     But  the 


Ovulation  and  Conception.  63 

most  probable  explanation  is  that  in  such  cases  mucus  is  displaced 
from  the  cervical  canal  by  pressure  due  to  impact  of  the  penis,  and 
that,  in  the  intervals  of  pressure,  semen  ascends  to  take  its  place 
out  of  the  pool  of  that  fluid  just  deposited  in  the  posterior  vaginal 
fornix. 

Period  of  Possible  Impregnation. — Since  the  spermatozoa  may 
remain  alive  in  a  suitable  medium  for  ten  days  or  more,  and  the 
ovum  may  occupy  probably  ten  days  in  descending  to  the  uterus,  it 
is  obvious  that  a  fruitful  coitus  may  take  place  almost  at  any  time, 
and  probably  at  any  time,  of  the  menstrual  cycle.  It  has  long  been 
believed  that  the  greatest  aptitude  for  conception  exists  shortly 
after  the  end  of  a  menstrual  period.  Nature  seems  to  give  some 
evidence  in  favour  of  this  view,  since  the  period  of  most  acute  sexual 
feeling  is  generally  just  after  the  end  of  menstruation,  although  this 
may  extend  also  to  the  time  just  preceding  the  flow.  A  similar  con- 
clusion may  be  drawn  from  a  comparison  of  the  duration  of  pregnancy 
in  cases  of  single  coitus  on  a  known  date  with  its  duration  as 
reckoned  from  the  end  of  the  last  menstrual  period.  The  former 
period  is,  on  an  average,  272  days,^  the  latter  278  days.^  It  may  be 
inferred  from  this  that  the  fruitful  coitus  probably  takes  place,  on 
an  average,  about  six  days  from  the  end,  or  ten  days  from  the 
beginning,  of  the  last  menstrual  period.  Recorded  cases  seem  to 
show  that  this  is,  at  any  rate,  a  possible  time  for  fruitful  insemination, 
as,  for  example,  two  instances  mentioned  by  Marion  Sims,  in  which 
pregnancy  followed  a  single  known  coitus  at  such  a  date,  and  one  in 
which  it  was  the  result  of  intra-uterine  injection  by  him  of  seminal 
fluid.  Raciborski  concluded,  arguing,  however,  from  only  fifteen 
cases  of  a  single  coitus,  that,  in  rather  more  than  half,  the  fertile 
coitus  occurred  in  the  two  days  following  menstruation. 

On  the  other  hand,  if  the  doctrine  mentioned  above  were  true, 
that  the  commencement  of  menstruation  is  a  sign  tbat  impregnation 
of  the  ovum  discharged  in  connection  with  that  period  has  failed,  it 
would  follow  that  coitus  is  least  likely  to  be  fruitful  just  after  the 
end  of  a  period,  and  most  likely  to  be  so  a  few  days  before  the 
onset  of  a  period.     It  is  a  strong  argument  against  this  doctrine 

^  Lowenhardt's  statistics  give  272  days  ("  Die  Berechnung  und  die  Dauer  der 
Schwangerschaft,"  Archiv  flir  Gyniikologie,  III.,  1872);  Ahlfeld's,  271  ("  Beo- 
bachtungen  Liber  die  Dauer  der  Schwangerschaft,"  Monatsschrift  flir  Geburtshiilfe, 
XXXIV.,  1869);  Stadfeldt's,  272  (Annales  de  Gynecologic,  VIII. ,  1877,  p.  227); 
Matthews  Duncan's,  275  (Fecundity,  Fertility,  and  Sterility,  Edinburgh,  1871)  ; 
"Dauer  der  Schwangerschaft,"  Fr.  v.  Winckel,  Handbuch  der  Geburtshiilfe,  1903, 
p.  648. 

'•^  According  to  Matthews  Duncan.  Lowenhardt  {op.  cit.)  reckons  282  days  from  the 
fmt  day  of  menstruation,  an  estimate  which  closely  corresponds  witli  that  of  Duncan. 


64  The  Practice  of   Midwifery. 

that  it  would  seem  a  strange  anomaly  of  nature  for  sexual  feeling 
to  be  strongest  exactly  at  the  time  when  impregnation  is  least 
likely.  Some  evidence  on  this  question  may  be  derived  from  the 
case  of  the  Jews.  In  the  Jewish  law,  Jewish  women  are  directed  to 
abstain  from  coitus  during  menstruation,  and  for  seven  days  after 
its  cessation.^  Strict  observers  of  the  law  are  said  to  go  beyond 
what  is  commanded  in  Leviticus,  and  even  if  the  discharge  lasts 
only  for  an  hour  or  two,  to  observe  five  days  during  which  the 
discharge  might  last,  for  the  period  itself,  and  add  to  these  seven 
clear  days,  making  twelve  in  all,  at  the  least.  Less  strict  observers 
of  the  law,  however,  keep  only  three  days  after  the  cessation  of  the 
flow,  or  merely  occupy  separate  rooms  while  it  actually  continues. 
It  is  much  to  be  doubted  whether,  whatever  may  be  laid  down 
in  the  Priestly  Code,  a  whole  nation  was  ever  induced  to  practise 
abstinence  at  the  period  of  most  acute  sexual  feeling.  It  is 
probable  that,  with  Jewesses  who  observe  strictly  the  Levitical 
law,  the  fertile  coitus  is  generally  shortly  before  the  period,  but 
there  are  no  statistics  as  to  the  duration  of  pregnancy  ffom  a 
single  known  coitus  in  those  who  observe  the  Jewish  law. 

If  the  conclusions  drawn  by  Teacher  and  Bryce^  are  correct  as  to 
the  age  of  the  early  human  ova  they  have  studied,  then  it 
follows  that  fertilisation  may  occur  at  any  time  during  the  inter- 
menstrual period,  although,  as  we  have  already  mentioned,  they 
think  that  pregnancy  is  most  likely  to  occur  when  insemination  and 
ovulation  take  place  simultaneously,  and  this  no  doubt  is  most 
probable  just  after  the  menstrual  period.  It  is  said  that  some  women 
conceive  only  when  coitus  takes  place  actually  during  the  men- 
strual flow  ;  but  it  is  comparatively  rarely  that  this  is  put  to  the 
test. 

^  See  Leviticus  xv.  19. 
-  Loe.  clt. 


Chapter  III. 

EARLY  DEVELOPMENT  OF  THE  OVUM. 

The  details  of  the  development  of  the  ovum  belong  to  embryo- 
logy, and  only  so  much  will  be  considered  here  as  is  necessary  in 
order  to  understand  the  formation  of  the  envelopes  of  the  foetus 
which  are  of  practical  importance  in  midwifery.     These  are,  from 


Fig.  42. — Formation  of  polar  bodies  in  Asterias  glacialis.  ps,  polar  spinale  ; 
ph',  first  polar  body ;  pb",  second  polar  body ;  n,  female  pronucleus. 
(After  Hertwig.) 

without  inwards,  the  decidua,  the  chorion,  and  the  amnion,  of 
which  the  first  belongs  to  the  uterus,  the  two  latter  to  the  ovum. 
The  earlier  of  the  changes  now  to  be  described  are  only  inferred 
to  take  place  from  the  analogy  of  what  occurs  in  the  lower 
animals,  and  some  of  the  earliest  have  not  been  observed  even  in 
mammals. 

Maturation  of  the  oocyte. — Maturation  occurs  independently 
of  impregnation,  and  consists  of  a  series  of  changes  which  prepare 
the  egg  for  fertihsation.  The  actual  process  has  not  been 
observed  in  the  human  ovum,  but  no  doubt  it  takes  place  in  the 
same  manner  as  in  some  of  the  lower  mammals,  in  which  the  whole 
series  of  changes  can  be  followed.  The  most  important  phase  in 
maturation  is  the  formation  and  throwing  off  of  the  so-called  polar 
bodies.^     The  germinal  vesicle  approaches  the  surface  of  the  ovum, 

'  The  polar  bodies  were  so  called  because  it  was  thought  that  their  presence 
determined  the  pole  of  the  egg  at  which  the  first  segmentation  took  place  after 
fertilisation  of  the  ovum  occurred. 

M.  5 


66  The  Practice  of   Midwifery. 

loses  its  membrane,  and  becomes  somewhat  smaller,  characteristic 
mitotic  changes  occur,  and  it  ultimately  undergoes  division,  so  that 
a  portion  of  it  becomes  budded  off  on  the  surface  with  a  small  part 
of  the  protoplasm  as  the  first  polar  body.  A  repetition  of  the 
same  process  leads  to  the  formation  of  the  second  polar  body, 
while  the  cell  remaining  now  forms  the  mature  ovum  (Fig.  42). 
At  times  the  first  polar  body  undergoes  further  division.  The 
oocyte  after  its  first  division  is  called  an  oocyte  of  the  second 
order,  and  when  it  again  divides  and  the  second  polar  body  has 
been  thrown  off,  it  is  termed  the  mature  ovum,  and  its  nucleus 
the  female  pronucleus.  The  second  polar  body  is  considered  to 
be  homologous  to  the  mature  ovum,  capable  therefore  of  becoming 


Fig.  43. — Formation  of  second  polar  body  of  the  mouse.  I.  First  polar 
body  («)  and  its  nucleus  {b)  with  second  polar  spindle.  II.  Second  polar 
body  with  remains  of  spindle  X  1,200  diameters.     (Sobotta.) 

fertilised,  and,  according  to  some  observers,  plays  a  part  in  the 
development  of  teratomata. 

The  nucleus  of  the  somatic  cells  contains  a  substance  called 
chromatin,  arranged  in  the  form  of  a  network,  which  during  the 
process  of  division  of  the  nucleus  forms  a  definite  constant  number 
of  filaments  or  rods  called  chromosomes.  It  is  computed  that  in 
the  body  cells  of  man  the  number  of  chromosomes  is  twenty-four. 
In  the  reproductive  cells,  both  male  and  female,  only  half  the 
number  of  chromosomes  normal  to  the  animal  is  found. 

The  reduction  in  the  number  of  chromosomes  is  effected  during 
the  maturation  of  the  sex  cells  and  the  throwing  off  of  the  polar 
bodies,  and  obviously  is  necessary  to  avoid  a  doubling  of  the  amount 
of  chromatin  in  the  process  of  fertilisation  in  each  successive 
generation.  By  the  fusion  of  the  male  and  female  pronucleus  the 
normal  number  of  chromosomes  is  again  constituted  in  the 
segmentation  nucleus. 


Early  Development  of  the  Ovum. 


67 


Fertilisation  and  Segmentation  of  the  Ovum. — The  details 
of  the  process  of  fertilisation  as  described  by  Sobotta^  and 
Melissinos^  in  the  mouse  are  as  follows: — The  spermatozoon  meets 
the  ovum  in  the  oviduct  before  the  throwing  off  of  the  second  polar 
body  is  completed,  and  finds  its  way  into  the  interior  by  piercing 
the  zona  pellucida.  The  head  of  the  spermatozoon  becomes  con- 
verted into  a  small  vesicular  nucleus,  the  male  pronucleus, 
smaller  than  the  germ  nucleus.  The  two  nuclei  approach  one 
another,  and,  now  of  equal  size,  come  to  lie  side  by  side.  Characteristic 
changes  occur  in  the  nuclear  network,  and  the  chromatin  becomes 
divided  up  into  the  chromosomes.  It  has  been  shown  in  Ascaris,  which 
has  only  four  chromosomes,  that  the  rods  are  divided  after  splitting 


D  ^'^-^  E  "==^-==^=^  F 

Fig.  44. — Segmentation  of  mammalian  ovum,     z.p.,  zona  pellucida  ;  p. b.,  polar 
bodies  ;  o.c,  outer  cells';  i.e.,  inner  cells  ;  s.c,  segmentation  cavity. 

between  the  two  first  blastomeres  in  such  a  way  that  each  receives  an 
equal  number  of  maternal  and  paternal  chromosomes  (Fig.  46,  p.  69). 
Too  much  importance  cannot  be  laid  on  this  fact,  since  the  chromatin 
is  the  material  basis  of  the  hereditary  qualities  handed  on  from  one 
generation  to  another.^ 

The  conjugation  of  the  sperm  and  germ  nuclei  into  the  segmenta- 
tion nucleus  is  immediately  followed  by  the  segmentation  of  the 
ovum,  the  egg  dividing  into  two  segments  or  blastomeres,  and,  as 

1  Sobotta,  Arch.  f.   Mikr.  Anat.,  1903,  Vol.  LXI..  p.  274. 

2  Melissinos,  Arch.  f.  Mikr.  Anat.,  1907,  Vol.  LXX.,  p.  .577. 

»  The  experiments  of  Boveri,  Delage,  and  others  have  shown  that  the  eggs  of  sea- 
urchins  containing  no  part  of  the  germ  nucleus,  when  fertilised  by  spermatozoa,  will 
undergo  .segmentation  and  form  larvic,  and  tiiat  these  eggs  also  can  be  made  to 
segment  and  form  larvaj  by  the  action  of  certain  physical  and  chemical  stimuli  without 
the  i)resencc  of  spcrmotozoa.  From  these  experiments  we  may  conclude  that  the 
union  of  the  male  and  female  nuclei  is  not  the  means  by  which  developmental  changes 
arc  initiated,  altiiough  it  is  the  most  important  factor  in  tl)e  process.  (T.  H.  Biyce, 
Quain's  Anatomy,  1908,  Vol.  I.,  p.  17.) 


68 


The  Practice  of   Midwifery. 


V. 


'I 


■•-\ 


II. 


III. 


^ 


IV. 


VI 


VII. 


Fig.  45.— Stages  in  the  fertilisation  of  the  egg  of  the  mouse.  (Sobotta.)  I.  Entrance 
of  spermatozoon.  II.  Rotation  of  sperm  head.  III.  Formation  of  sperm  nucleus, 
which  lies  to  the  left ;  the  germ  nucleus  lies  to  the  right.  IV.  Resolution  of 
■  nuclei.  V.  Vesicular  stage  of  nuclei.  VI.  Enlargement  of  sperm  nucleus  and  its 
approach  to  germ  nucleus.  VII.  First  segmentation-spindle  with  group  of 
paternal  chromosomes  to  left,  and  of  maternal  to  right. 


Early  Development  of  the  Ovum.  69 

has  been  pointed  out,  each  of  these  receives  an  equal  complement  of 
maternal  and  paternal  chromosomes  (Fig.  46).  Each  of  the  two 
primary  segments  now  divides  again,  and  thus  a  group  of  four 
segments  is  formed,  each  of  which  in  its  turn  divides,  until  a  small 
mass  is  produced  called  the  mulberry  mass  or  morula. 

At  this  stage,  while  the  new  cells  are  still  enclosed  within  the  zona 
pellucida,   and  the  whole  is  but  little,  if  at  all,  larger  than  the 


Fig.  46. — Diagram  of  fertilisation.  Paternal  chromosomes  black,  maternal 
white.  (Modified  after  Boveri.  Quain's  Anatomy,  Vol.  I.,  Embryology, 
T.  H.  Bryce.) 


ovum  from  which  it  is  derived,  a  distinction  between  the 
cells  can  be  perceived,  the  centre  being  occupied  by  larger, 
more  granular  cells,  the  outer  layer  consisting  of  smaller,  clearer 
elements.  Fluid  now  accumulates  in  the  centre  of  the  mass,  and 
almost  completely  separates  the  outer  layer  of  cells  from  the  inner 
except  at  one  point.  The  outer  layer  proliferating,  is  converted 
into  the  so-called  trophobiaet,  and  plays  an  important  part  in  the 
embedding  and  nourishing  of  the  early  ovum,  while  the  central 
mass  forming  the  formative  or  embryonic  cell  mass  takes  part  in 


70 


The  Practice  of   Midwifery. 


the  formation  of  the  embryo,  the  yolk-sac,  and  in  man  and  apes 
almost  certainly  the  amnion.  The  ovum  at  this  stage  of  development 
is  termed  the  blastocyst. 

In  the  mouse  the  zona  pellucida  persists  after  the  ovum  has 
reached  the  uterus,  and  only  disappears  as  it  is  becoming  embedded. 
The  early  stages  of  cleavage  of  the  human  ovum  have  not  been 
seen,  the  earliest  known  ovum  (Teacher — Bryce)  having  already 
advanced  beyond  the  stage  of  the  blastocyst  and  measuring 
1-95  X  -95  X  1-1  mm. 

Before  describing  the  further  changes  in  the  ovum  after  it  has 


Fibrin. 


Fibrin. 


Ovum 


Vessel.   - 
Gland.    - 


Fibrin. 

Cavity  of 
Ovum, 


Gland 
Vessel 


Ovum. 


-  Vessel. 
Gland. 


Fibrin. 

Coeloma 
Externum. 


Vessel. 


D    /  I  (#r-^ 


Gland. 
Gland. 


Embryo. 
Fig.  47. — Diagi-am  of  embedding  of  ovum  and  formation  of  decidua  capsularis 
and  basalis.      The  uterine  vessels  are   indicated  by  thinner  lines,   the 
glands  by  thicker  lines.     (After  Peters.) 


reached  the  uterus,  it  is  well  to  consider  the  changes  in  the  uterus 
itself  which  result  in  the  formation  of  the  decidua  or  the  outermost 
of  the  three  envelopes  of  the  ovum. 

The  Decidua. — On  reaching  the  uterus  the  ovum  becomes 
attached  as  a  rule  at  a  point  not  far  from  the  orifice  of  the  Fallopian 
tube,  most  frequently  on  the  posterior  wall.  The  proliferation  of 
the  mucous  membrane  to  form  the  decidua  used  to  be  described  as 
commencing  from  the  moment  of  the  fertilisation  of  the  ovum,  but 
it  is  more  probable  that  it  only  begins  when  the  ovum  becomes . 
attached,  and  so  exercises  its  stimulating  influence  on  the 
surrounding  tissue. 


Early  Development  of  the  Ovum.  71 

It  was  formerly  believed  that  the  ovum  on  arriving  in  the 
uterus  was  already  provided  with  villi ;  that  it  attached  itself  by 
means  of  these  villi  to  the  surface  of  the  uterus;  and  that  the 
mucous   membrane   then   grew  up   round   it   until   it   completely 


Fig.  48. — Pregnant  uterus  showing  very  early  ovum  embedded  in  posterior 
v^all.  Site  indicated  by  black  dot  (Peters,  Einbettung  des  Men- 
schlichen  Eies.) 


covered  it  in,  and  shut  it  off  by  a  septum,  the  decidua  refiexa,  from 
the  cavity  of  the  uterus. 

A  study  of  several  very  early  human  ova  recently  described  by 
Leopold,^    Spee,^  Peters,'^  Teacher   and  Bryce,*  and   Jung,'""  all  of 

'   Utei'us  uiid  Kind,  Leipzig,  1897. 

2  Arch,  f .  Anat.  und  Phys.  ;  Anat.  Abtheil.,  1896,  pp.  1—30,  IhUl.,  1899,  pp.  1.59—170. 

■^  Ueber  die  Einbettung  des  Menschlichen  Eies,  Wien,  1899. 

''  The  Early  Development  and  Imbedding  of  the  Human  Ovum,  1908. 

'■  Beitiiigezur  Friilie.sten  EieinbeLtung  beim  Menschlichen  Weibe,  Berlin,  1908. 


72  The  Practice  of   Midwifery. 

which   are  ah'eady  completely  embedded  m  the  uterme   mucous 
membrane,  has  shown  that  the  cells  of  the  trophoblast  have  the 


Gl    Ca        M        Tr 

1     !       \       \ 


U  E     a 

\       i      -% 

1      ■       / 


B  L 


Sy 


B 


/ 


-Sy 


Ir 


Ca 


B  L 


/■ 


^  f^  i> 


Sy 


}  U  E 


E 


/ 

Gl 


M 


Com 


Ca 


GlTr       B      Ca 


Fia.  49.— Section  through  centre  of  Peters'  ovum,  supposed  to  have  been  implanted 
in  the  uterus  about  seven  days. 

a — S,  aperture  of  entry  ;  F,  cap  of  organising  fibrin  ;  E,  embryonic  area ;  M^  mesoblast ; 
Tr,  trophoblast ;  Sy,  syncytium  ;  Z>,  decidual  cells ;  Com,  compact  layer  of 
decidua  ;  TJ  E,  uterine  epithelium  ;  B  L,  blood  lacunae  ;  Ca,  capillaries  ;  Gl, 
uterine  glands. 

power  of  dissolvmg  the  maternal  tissues,  probably  by  the  formation 
of  some  enzyme. 

These  observations  demonstrate  that  the  ovum  attaches  itself 
either  in  the  morula  or  early  blastocyst  stage,  as  in  the  guinea-pig. 


Early  Development  of  the  Ovum.  73 

to  the  mucous  membrane,  immediately  burrows  into  it,  and  pro- 
ceeds to  develop  there,  the  villi  being  formed  ultimately  within  the 
substance  of  the  uterine  mucous  membrane.  The  minute  aperture 
of  entry  is  covered  at  first  only  by  a  small  soft  thrombus  which 
becomes  organised  into  fibrous  tissue.  The  position  of  the  ovum  is 
not  marked  by  any  projection  above  the  general  surface  of  the  mucous 
membrane,  as  seen  in  Peters'  ovum,  which  was  supposed  to  have 
been  attached  about  seven  days  (Fig.  49).  The  decidua  reflexa  is  at 
first  simply  that  part  of  the  general  mucous  membrane  or  decidua 
vera  which  the  ovum  has  undermined,  with  the  minute  cicatrix, 
Eeichert's  scar,  at  its  centre.  As  the  ovum  grows  the  glands  of 
the  mucous  membrane,  partly  destroyed  by  the  trophoblast  and 
partly  pushed  aside,  become  placed  concentrically  around  it  (C,  D, 
Fig.  47).  As  the  decidua  reflexa  or  capsularis  reaches  its  greatest 
development,  before  coming  into  contact  with  the  decidua  vera, 
the  main  part  of  it  is  formed  by  the  growth  of  what  was  originally 
the  central  portion,  and  gland  cavities,  with  their  openings  into 
the  cavity  of  the  uterus,  are  seen  only  near  the  margin  where 
it  is  attached  to  the  uterine  wall.  The  central  part  of  the  decidua 
reflexa,  as  the  ovum  is  embedded  in  the  stratum  compactum  alone, 
resembles  the  superficial  portion  of  the  decidua  vera,  and  contains 
no  glands. 

The  mucous  membrane,  proliferating  in  consequence  of  the 
stimulus  of  pregnancy,  thus  forms  the  decidua.  The  name  decidua 
is  employed,  because  the  membrane  is  cast  off  from  the  uterus  at 
the  end  of  pregnancy.  That  portion  of  the  developing  mucous 
membrane  to  which  the  ovum  is  attached  was  called  the  decidua 
serotina  and  forms  eventually  the  site  of  the  placenta,  the  rest  of  the 
mucous  membrane  lining  the  uterus  was  called  the  decidua  vera,  and 
the  portion  which  covers  the  ovum  from  the  uterine  cavity  was  called 
the  decidua  rejiexa. 

The  inappropriate  names  given  to  the  several  portions  of  the 
decidua  originated  from  a  false  theory  of  its  origin.  The  decidua 
was  correctly  figured  by  William  Hunter  as  being  the  developed 
mucous  membrane.  John  Hunter,  however,  believed  that  it  was 
a  layer  of  coagulable  lymph  poured  out  from  the  surface  of  the 
uterus,  and  this  view  was  long  accepted  by  anatomists.  It  was 
supposed  that  this  layer  covered  the  surface  of  the  uterus, 
including  the  orifices  of  the  Fallopian  tubes,  before  the  ovum  had 
emerged  from  the  tube.  The  ovum,  on  arriving  at  the  orifice  of 
the  tube,  pushed  a  portion  of  the  layer  of  lymph  before  it  into 
the  uterus,  and  this  portion  was  called  the  decidua  reflexa.  The 
portion  of  the  layer  which  remained  undisturbed  was  the  decidua 


74  The  Practice  of   Midwifery. 

vera.  Finally,  it  was  supposed  that  a  fresh  layer  of  lymph  was 
poured  out  between  the  uterine  wall  and  the  ovum,  and  this,  as 
being  formed  later,  was  called  the  decidua  serotina  (from  serus,  late). 
The  terms  decidua  basalis  instead  of  decidua  serotina  and  decidua 
cai^sidaris  instead  of  decidua  refiexa  are  now  coming  into  general 
us&. 

Thus,  in  the  early  stage  of  pregnancy,  there  is  a  decidual  cavity, 
which  is  in  fact  the  cavity  of  the  enlarging  uterus,  the  ovum 
forming   a   prominence  projecting  into  it.     The  cavity  has  three 


Fig.  50. — Decidual  cells  from  early  pregnancy. 

openings,  the  os  uteri  and  the  orifices  of  the  two  Fallopian  tubes. 
The  Fallopian  tube,  however,  from  which  the  ovum  descended,  is 
liable  soon  to  be  occluded  by  its  growth.  The  existence  of  the 
decidual  cavity  explains  the  fact  that  a  sound  may  be  passed  into 
the  uterus  within  the  first  three  months  of  pregnancy  without 
rupturing  the  ovum,  and  sometimes  without  interruption  to  the 
pregnancy,  and  also  the  fact  that,  in  some  exceptional  cases,  men- 
struation may  continue  during  the  first  three  months  of  pregnancy. 
The  stroma  of  the  decidua  is  made  up  of  the  characteristic 
decidual  cells.  These  are  large  round,  oval,  or  polygonal  cells  with 
large  nuclei.  In  a  section  they  are  epithelioid  in  appearance  ;  but, 
if  separated  by  oedema  of  the  tissue  or  otherwise,  many  of  them  are 


Early  Development  of  the  Ovum. 


75 


seen  to  have  protoplasmic  outgrowths  which  join  similar  outgrowths 
from  neighbouring  cells  (Fig.  50).  It  is  now  generally  agreed  that 
they  arise  by  hypertrophy  of  the  connective  tissue  cells  of  the 
stroma  of  the  unimpregnated  uterus.  But  it  is  not  always  easy  to 
distinguish  them  in  a  section  from  epithelial  cells.  Thus,  at  an 
early  stage  in  the  growth  of  the  placenta,  groups  of  cells  are  seen 
amongst  the  villi  which  used  to  be  regarded  as  "  decidual  islands." 
Many  authorities  now  consider  that  these  belong  to  the  foetal 
trophoblast,  and  corresj)ond  to  the  cells  of  Langhan's  layer,  or 
deeper  layer  of  chorionic  epithelium,  although  no  direct  continuity 
with  Langhan's  layer  can  generally  be  traced.  As  a  rule,  the 
decidual  cells  have  a  smaller  nucleus 
in  proportion  than  the  cells  of  the 
trophoblast. 

The  thickness  of  the  decidua  is 
much  greater  at  the  early  stage  of 
pregnancy  than  in  the  later  months, 
both  absolutely  and  still  more  in 
proportion  to  the  bulk  of  the  ovum. 
The  greatest  thickness,  which  may  be 
as  much  as  ^  inch  for  the  decidua  vera, 
is  attained  by  the  third  month.  By 
that  time  the  decidua  capsularis  has 
already  been  thinned  by  stretching. 
The  decidua  vera  and  decidua  capsu- 
laris come  into  contact  at  the  fourth 
month,  and  are  blended  together,  the 
decidual  cavity  is  obliterated,  and  the 
ovum  occupies  the  whole  of  the  body  of 
the  uterus.    From  this  time  the  decidua 

caj^sularis  becomes  gradually  stretched  into  a  structureless  lamella, 
which,  after  the  sixth  month,  cannot  generally  be  detected  as  a 
distinct  membrane.  The  decidua  vera,  at  term,  is  reduced  to  about 
j;-  inch  in  thickness,  or  about  one-fifth  of  the  thickness  which  it 
had  at  the  third  month. 

Decidua  Vera. — The  decidua  vera,  in  its  growth,  gradually 
becomes  divided  into  two  layers,  a  compact  layer  nearest  the 
surface,  and  a  sjjongi/  or  (jlandular  layer  nearest  the  muscular  wall  of 
the  uterus,  and  forming  the  greater  part  of  the  thickness  of  the 
membrane  (Fig.  54,  p.  78).  The  compact  layer  is  made  up  of  the 
characteristic  decidual  cells,  with  but  little  intercellular  substance. 
In  the  earlier  months  the  ducts  of  the  uterine  glands  may  be 
seen  traversing  it,   and  there  are  numerous   thin-walled  vessels. 


Fig.  51. — Section  of  ovum  in  situ 
at  beginning  of  second  week, 
showing  decidua  capsularis 
formed.     (After  Leopold.) 


76 


The  Practice  of   Midwifery. 


Leucocytes  are  seen  among  the  large  cells,  and  numerous  lymph 
spaces  are  believed  to  exist,  especially  around  the  vessels  and  the 
gland-ducts.  The  surface  epithelium  gradually  loses  its  elongated 
cylindrical  sha]3e,  and  becomes  cuboid  or  flattened.  This  change 
is  considered  to  be  decisive  evidence  of  pregnancy.  After  the 
junction  of  the  decidua  vera  and  capsularis  (about  the  third  month), 
surface  epithelium  is  no  longer  discoverable. 

The   spongy  layer   is  made  up  of  proliferating  glands  with  a 


Amnion 
d  embryo 


Maternal 


Decidua 
capsularis 


Chorionic  memiirane 

Chorionic   vdh 


Chono  decidual 
apace 


Fig.  52. — The  same  ovum  magnified. 


minimum  of  interglandular  stroma.  The  cells  of  the  stroma 
are  smaller  than  those  of  the  compact  layer,  not  so  round,  but 
more  frequently  spindle-shaped,  and  there  is  more  intercellular 
substance.  The  glands  at  first  are  lined  by  typical  cylindrical 
uterine  epithelium,  but  this  gradually  becomes  more  cuboidal 
in  shape,  and  eventually  is  cast  off  to  a  great  extent.  Toward 
the  end  of  pregnancy  the  gland  cavities  become  arranged  as  large 
flattened  spaces  parallel  to  the  uterine  wall.  These  constitute  the 
ampullary  layer,  which  is  much  thinner  than  the  spongy  layer  in  the 
early  months,  and  was  believed  to  form  the  surface  of  separation 


Early  Development  of   the  Ovum.  77 

when  the  decidua  is  thrown  off.  Beneath  it  there  is  a  very  thin, 
deeper  and  more  compact  layer  of  decidual  tissue,  which  remains 
attached  to  the  muscular  wall  (Fig.  53).  The  spaces  of  the 
ampullary  layer  have  generally  lost  their  epithelial  lining,  but 
some  epithelium  remains,  especially  in  the  ends  of  the  glands, 
which  dip  into  the  deeper  compact  layer. 

Decidua  Refiexa  or  Cajjsidaris. — Within  a  few  hours  after  its 
attachment  to  the  mucous  membrane  the  ovum  is  believed  to  be 
shut  off  from  the  uterine  cavity  by  the  decidua  capsularis.     The 


A' 


ci. 


"^V^'^^rrs'  •*>- 


— J — ~«*Ssa:i^i>_ 


^   ^  '^ 


/    Sf       /C*       - 


Fig.  53. — Membranes  in  situ,  from  near  margin  of  placenta,  r,  chorionic 
villus  ;  cun,  amnion  ;  ch,  chorion  ;  c.l.,  compact  layer  of  decidua ; 
sjJ.l,  spongy  layer  ;  m,  muscle  of  uterine  wall. 


decidua  capsularis  usually  attains  its  greatest  thickness  at  about 
the  second  month.  It  is  made  up  of  decidual  cells,  and  is  covered 
at  first  on  its  exterior  by  a  single  layer  of  cuboidal  or  flattened, 
epithelial  cells.  Near  the  border  where  it  is  attached  to  the  uterus 
a  few  gland-ducts  may  be  detected,  opening  on  its  outer  surface. 
Its  inner  surface,  in  contact  with  the  chorionic  villi  which  are 
attached  to  it,  is  not  covered  with  epithelium,  and  no  gland-ducts 
open  in  it. 

Decidua  Serotina  or  liasalis. — The  decidua  basalis  is  that  portion 
of  the  decidua  which  lies  immediately  beneath  the  ovum.  It  is 
seen  as  a  separate  layer  only  on  the  uterine  surface  of  the  placenta 


78 


The  Practice  of   Midwifery. 


but  the  whole  mass  of  the  placenta  is  really  formed  in  relation 
with  it.  Its  structure  will  be  described  in  conjunction  with  the 
development  and  structure  of  the  placenta. 

In  the  early  stage  of  pregnancy  the  growing  ovum  does 
not  nearly  fill  the  uterine  cavit}^,  which  grows  faster  than  the 
ovum.     Thus   there    remains   a  considerable  space,  the  decidual 


f  x,-^ 


^\   ^ 


.>  .'       ^  i^ 


(  )mpact 
"  ucr. 


1 


"^^^  1  ij  cr. 


Muscular 
UwaU. 


Fig.  'A. — Section  of  decidua  vera  at  fourth  month,      x  1.3. 
(After  Whitridge  Williams.) 


cavity,    between  the   decidua  capsularis  and  decidua  vera.      (See 
Fig.  119,  p.  175.) 

In  an  early  abortion  the  openings  of  the  glands  may  be  seen 
with  the  naked  eye,  or  more  clearly  with  a  lens,  on  the  smooth 
internal  surface  of  the  decidua  vera,  and  the  same  appearance 
may  be  seen  when  the  uterus  is  opened  before  the  tliird  month  of 
pregnancy.  No  such  openings  are  seen  on  the  decidua  capsularis, 
except  at  a  very  early  stage,  close  to  its  border.     Before  the  full 


Early  Development  of  the  Ovum. 


79 


term  of  pregnancy  coagulation  necrosis  of  the  decidua  takes  place 
preparatory  to  its  separation.  By  the  fourth  month  the  decidua 
reflexa  has  lost  its  vascularity,  and  atrophic  changes  have  already 
commenced  in  the  decidua  vera,  the  result  of  the  pressure  and 
distension  which  it  undergoes. 

The  decidua,  as  its  name  implies,  is  cast  off  at  the  end  of 
pregnancy,  and  there  has  been  a  controversy  whether  the  mucous 
membrane  is  thrown  off  completely,  so  that  the  muscular  wall  of 
the  uterus  is  laid  bare.  The  truth  appears  to  be  that  more  or  less 
of  the  extremities  of  the  glands  is  left,  with  their  epithelium,  in 
the  deeper  compact  layer  of  decidual  tissue  which  remains  attached 
when  the  decidua  is  thrown  off  by  detachment  through  the  outer 
part  of  the  compact  layer  or  its  junction  with  the  spongy  layer.^ 


Primitive  groove, 

Mesoderm . 

Amnial  fold .  ^ 

^^ 

w 

Ectoderm.^      ^i 

1^    wi 

Visceral          "m 

^%    MR 

mesoderm.  ""_># 

1    ^:3Ml%\ 

Ectoderm. 

^  Entoderm . 

,  Ccelom. 

Parietal 
mesoderm . 


Coelom.  Coelom. 

Fig.  .5.5. — Transverse  section  of  embryonic  area  of  a  sheep.     (After  Bonnet.) 

These  form  the  starting  point  for  the  renewal  of  the  glandular 
tissue ;  and  the  surface  epithelium  is  derived  from  the  epithelium 
of  the  gland-tubes  like  that  of  the  uterus  after  menstruation.  The 
remnant  of  decidual  tissue  remaining  attached,  is,  however,  so  soft, 
that  it  may  readily  undergo  post-mortem  disintegration  after 
delivery  at  full  term.  A  certain  portion  of  the  decidua  vera  comes 
away  attached  to  the  chorion  ;  the  remainder  is  discharged  in  pieces 
with  the  lochia.  A  thin  layer  of  the  decidua  basalis,  pierced  by  the 
openings  of  the  placental  vessels,  comes  away  on  the  uterine  surface 
of  the  placenta. 


Further  Changes  in  the  Ovum. — There  are  many  gaps  in  our 
knowledge  of  tlie  development  of  the  early  human  ovum,  but  from 
the  worlv  which  has  1)eeri  carried  out  by  Hubrechfc  on  Tarsius,  one 
of  the  lemurs,  Selenka  and  others  on  some  of  the  apes  and  monkeys, 
together  with  the  facts  obtained  by  a  study  of  the  numerous  early 

*  J.  G.  Webster,  Human  Placeatation,  lliOl. 


8o  The  Practice  of   Midwifery. 

human  ova  which  have  now  been  described,  we  are  able  to  trace 
with  a  fair  degree  of  certainty  the  changes  which  occur  in  the  first 
stages  of  the  development  of  the  foetus.  In  the  blastocyst,  as 
already  mentioned,  the  outer  covering  consists  of  the  cells  of  the 
trophoblast,  and  forming  a  projection  into  the  interior  is  the  for- 
mative or  embryonic  cell  mass.  The  first  change  is  the  formation  of 
the  primitive  entoderm  by  the  splitting  off  from  the  lower  margin 
of  the  cell  mass  of  a  layer  of  cells  which  ultimately  form  a  small  sac, 
the  entodermic  or  yolk-sac,  separated  by  a  considerable  space  from 
the  wall  of  the  trophoblast  (Fig.  60,  p.  83).  In  the  next  phase 
after  the  formation  of  the  entoderm  a  space  develops  by  splitting 


/ 


Fig.  56. — Embryonic  area  of  the  rabbit  showing  two  stages  in  the  develop- 
ment of  the  mesoderm  (Kolliker).  In  A  the  mesoderm  extends  on  either 
side  of  the  primitive  streak  over  the  posterior  part  of  the  embryonic  area, 
and  also  behind  the  primitive  streak,  in  B  the  mesoderm  extends  over 
a  circular  area  surrounding  the  embryonic  area,  which  is  trilaminar 
except  in  the  middle  line  in  front  of  the  primitive  streak. 

in  the  middle  of  the  cells  of  the  cell  mass,  the  so-called  amnio- 
embryonic  cavity.  The  cells  forming  the  floor  of  this  cavity 
undoubtedly  remain  as  the  embryonic  ectoderm,  while  the  fate  of 
the  cells  of  the  roof  is  a  matter  of  dispute.  In  the  lemur  they 
disappear,  so  that  the  ectoderm  comes  to  the  surface  and  is  exposed, 
but  in  the  higher  apes  and  man  in  all  probability  they  persist 
(Bryce),  so  that  the  cavity  becomes  the  true  amniotic  cavity,  and  the 
embryonic  ectodermic  cells  never  reach  the  surface.  The  amnion 
in  man,  therefore,  from  the  very  first  is  a  closed  cavity,  and  the 
cells  forming  its  roof  are  attached  to  the  inner  surface  of  the 
trophoblast  by  a  solid  stalk,  the  so-called  connecting  stalk. 

Formation  of  the    Mesoderm. — In  order    to    understand   the 
formation  of  the  amniotic  folds  in  the  lower  mammals,  such  as 


Early  Development  of  the  Ovum. 


8i 


the  rabbit,  it  will  be  necessary  to  consider  the  development  of  the 
mesoderm  in  them  before  passing  on  to  a  consideration  of  its  forma- 
tion in  the  human  ovum  (Fig.  56).  At  one  end  of  the  oval-shaped 
embryonic  area  a  dark  line  appears,  the  primitive  streak  produced 
by  a  thickening  of  the  ectoderm,  and  from  the  lateral  borders  of 
this  newly  formed  cells  are  found  to  be  extending  into  the  space 
between  the  ectoderm  and  entoderm,  forming  the  mesoderm.  These 
cells  gradually  extend  all  round  the  blastocyst  and  also  forwards  in 


Choi-ion         Amalotic  sac 


Ventral 
5  tal  K 


E,mbr;yo 


Amniotic  3ft.c 


Amniotic   sac 


Fig.  57, — Scheme  of  formation  of  the  amnion. ^ 


front  of  the  primitive  streak  by  the  side  of  the  developing  embryonic 
axis.  At  this  stage  commences  a  cleavage  of  the  mesoderm  into 
two  layers,  so  that  the  outer  layer  is  comjDosed  of  the  mesoderm 
with  part  of  the  ectoderm,  the  inner  layer  of  the  rest  of  the 
mesoderm  with  the  entoderm.  The  outer  layer  is  called  the 
somatopleure  (snq)  in  Fig.  58),  and  that  part  of  it  which  belongs 
to  the  region  of  the  embryo  forms  the  body  walls.  The  inner 
layer  is  called  the  splanchnopleure  {sj)2^  in  Fig.  58),  and  that  part 
of  it  which  belongs  to  the  region  of  the  embryo  forms  the  wall  of 
the    alimentary   canal   (i,   Figs.    58,    59).      The   cleavage  is   not 

'    \'oi]  Wiiickel,  Handbuch  der  GebuitshUlfe,  \WA,  Vol.  I.,  Tt.  I.,  p.  272. 
M.  0 


82 


The  Practice  of   Midwifery. 


confined  to  the  border  of  the  region  of  the  embryo,  but  eventu- 
ally extends  completely  round  to  the  opposite  pole  of  the  yolk-sac, 


Fig.  58. — Diagrammatic  transverse  sections  of  embryo  and  ovum  in  lower 
mammals  to  illustrate  cleavage  of  mesoderm  and  formation  of  amnion. 
af.  amnial  fold  ;  a,  amnion  ;  ac.  amnial  cavity  ;  y,  yolk-sac  ;  v,  intestine  ; 
e,  epiderm ;  m,  mesoderm;  11,  hypoderm  ;  sm2),  somatopleure ;  sjJlJ, 
splanchnopleure  ;  ce,  cceloma  externum  ;  ci,  coeloma  internum.  The 
size  of  the  emlaryo  in  proportion  to  the  ovum  is  exaggerated  in  the 
figures.     (See  Figs.  49,  p.  72,  and  64,  p.  86.) 

and  the  yolk-sac  thus  becomes  a  free  vesicle  within  the  ovum  (see 
Figs.  58,  59).  The  space  between  the  two  layers  formed  by  the 
cleavage  of  the  mesoderm  is  called  the  coelom.  The  embryo, 
especially  at   its   head   end,  now  sinks  into  the   interior   of   the 


Early  Development  of  the  Ovum. 


83 


blastocyst,  and  a  fold  of  the  somatopleure  grows  up  round  it  from 
its  cephalic  and  caudal  extremities  and  from  its  sides.  The  embryo 
thus   becomes   surrounded    with   a  hollow   wall,  which  grows   up 


Fig.  59. — Diagrammatic  longitudinal  sections  to  illustrate  the  formation  of 
the  allantois  in  some  of  the  lower  mammals.  ;,  interior  of  alimentary- 
canal  ;  y,  yolk-sac  or  umbilical  vesicle ;  2)}),  pleuro-peritoneal  space, 
comprising  cceloma  internum  -and  coeloma  externum  ;  a,  amnion ; 
ac,  amnial  cavity  ;  al,  allantois. 

towards  its  dorsal  surface,  most  rapidly  around  the  head,  and 
arches  over  its  back,  converging  until  it  meets  in  the  centre  and 
covers  it  in  entirely.     The  fold  consists  of  an  outer  and  inner  leaf. 


e^f 


^ 


Vie/  'f^rc^SV 


£ 


\1    ^ 


<^    


@> 


Fig.  (>0, — Diagram  of  early  ovum  to  show  origin  of  mesoderm,  modified  after 
Teacher  and  Bryce.  ?«,  mesoderm  ;  ent,  entoderm  ;  e\n,  embryonic  cell 
mass  ;  am,  amniotic  cavity  ;  nt,  connecting  stalk  ;  t,  trophoblast. 

When  it  meets  over  the  centre  of  the  back,  the  double  septum 
between  its  different  parts  (c,  Fig.  58)  is  absorbed,  and  the  outer 
leaf  (sometimes  called  the  false  amnion)  remains  as  tbe  outer 
surface  of  the  ovum,  eventually  forming  part  of  the  chorion,  the 

0—2 


84 


The  Practice  of   Midwifery. 


zona  pellucida  having  disappeared.  The  inner  leaf  becomes  the 
true  amnion  (a  in  c,  Fig.  58),  and  encloses  the  amnial  cavity  (ac). 
The  fluid  afterwards  poured  out  into  the  amnial  cavity  is  called  the 
liquor  amnii,  or  amniotic  fluid. 

In  the  lemur,  and  probably  also  in  man,  the  mesoderm  is 
developed  at  an  earlier  stage  and  in  a  somewhat  different  manner 
(Fig.  60).  The  first  signs  of  it  are  to  be  found  in  a  mass  of  cells 
which  take  origin  from  the  posterior  extremity  of  the  embryonic  area, 
and  growing  outwards  along  the  amnion  stalk,  ultimately  surround 


Entoderm. 


Mesoderm. 


Part  of  coelom . 

Trophoblast. 
Mesoderm. 

Entoderm. 

Amnial  cavity. 

Embryonic 
ectoderm. 

Yolk-sac. 

Mesoderm. 


Pig.  61. — Embryonic  area  in  Peters'  ovum,  highly  magnified. 

the  yolk-sac,  the  amnion,  and  the  inner  surface  of  the  trophoblast. 
A  thickened  portion  of  this  mesoderm  from  a  very  early  stage  forms 
a  connecting  band  between  the  posterior  end  of  the  embryonic  area 
and  the  trophoblast,  the  so-called  connecting  stalk  (Haftstiel). 
This  connecting  stalk  is  a  most  important  feature  in  the  early 
development  of  the  human  ovum.  Not  only  does  the  primitive 
mesoderm  form  a  lining  for  the  trophoblast  and  the  yolk-sac,  but, 
as  Teacher  and  Bryce^  have  shown  from  their  study  of  an  early 
human  ovum  about  thirteen  to  fourteen  days  old,  it  completely  fills 
the  blastocyst  (Fig.  60).     Indeed,  they  incline  to  the  view  that  the 

1  The  Early  Development  and  Imbedding  of  the  Human  Ovum,  T.  H.  Bryce  and 
J.  H.  Teacher,  1908. 


Early  Development  of  the  Ovum.  85 

mesoderm  arises  at  even  an  earlier  stage  than  is  here  described, 
and  think  that  it  may  take  origin  concurrently  with  the  entoderm 
from  the  embryonic  cell  mass,  so  that  the  entoderm  from  the  very 
first  is  differentiated  into  an  epithelial  layer  forming  the  lining 
for  the  yolk-sac  and  a  vascular  mesenchyme  which  gives  origin  to 
the  vessels  of  the  connecting  stalk  and  chorion,  and  the  blood  and 
bloodvessels  of  the  yolk-sac.  The  very  early  development  of  the 
mesoderm  in  point  of  time  in  the  human  ovum  is  shown  by  the 
fact  that  up  to  now  the  primitive  streak  has  not  been  formed.    This 


Fig.  62. — Embryo  of  2  mm.  about  thirteen  days  old.  (After  Graf  v.  Spee, 
from  Volkmann's  Entwickelungsgeschichte).  y  s,  yolk-sac  ;  am,  amnion  ; 
n  gr,  neural  groove  ;  n  c,  neurenteric  canal  ;  p  str,  primitive  streak  ; 
ah  st,  abdominal  stalk. 

now  makes  its  appearance  on  the  germinal  disc,  and  from  its  sides 
a  further  development  of  mesoderm  takes  place. 

On  the  upper  surface  of  the  primitive  streak  a  shallow  groove  is 
formed  by  the  upgrowth  of  two  folds  of  ectoderm,  the  neural  folds, 
and  from  the  thickened  ectoderm  of  the  groove  develops  the 
central  nervous  system.  From  the  portions  of  the  mesoderm  lying 
on  either  side  of  the  neural  folds  the  primitive  mesodermic  segments, 
or  proto-vertebrae,  of  the  trunk  are  developed. 

It  will  not  1)0  necessary  for  us  to  consider  the  development  of  the 
human  embryo  any  further,  since  the  rest  of  the  stages  have  no 
immediate  bearing  on  our  subject. 


86 


The  Practice  of   Midwifery. 


The  Amnion.— The  amnion  is  at  all  times  non-vascular,  with 
the  possible  exception  mentioned  below.  It  has  a  single  layer  of 
cuboidal  epithelium,  corresponding  to  the  epidermis,  and  looking 
inward  toward  the  amniotic  cavity.     Outside  this  there  is  a  layer  of 


Embryonic  area. 


Chorion . 


Amnial  cavity. 
Abdominal  pedicle 

Chorion. 


Yolk-sac.  Allantois. 

Fig.  63. — Section  of  Spee's  human  ovum  at  early  part  of  second  week. 

embryonic  connective  tissue,  derived  from  the  mesoderm,  in  which 
are  seen  spindle  and  stellate  cells. 

The  amnion  is  at  first  separate  from  the  inner  surface  of  the  chorion, 
a  semi-liquid  gelatinous  substance,  the  mesenchyme,  occupying  the 


Chorionic  villi 


\0X  :k^. 


'Embryonic  area. 

Amnial  cavity. 
Abdominal  pedicle. 

Chorion. 


Constriction  betw^een  yolk-sac 
and  embryonic  area. 

Fig.  64. — Spee's  human  ovum  at  early  part  of  second  week. 

intervening  space  {pp  Fig.  59).  By  the  middle  of  pregnancy 
the  amnion  comes  into  close  contact  with  the  chorion,  only  a 
little  gelatinous  material  remaining  between  them.  The  amnion 
is  always  easily  separable  from  the  chorion,  although  it  adheres 
to  it  slightly.  Exceptionally,  fluid  (false  liquor  amnii)  is  still 
found  between  the  two,  even  at  the  full  term  of  pregnancy.  In 
such  case,  after  one  bag  of  water  (the  chorion)  has  been  ruptured 


Early  Development  of  the  Ovum.  87 

in  labour,  a  second  (the  amnion)  may  be  found  still  intact.  Some 
authorities  describe  vessels  as  existing  in  the  gelatinous  substance 
between  amnion  and  chorion,  and  as  having  a  function  in  the 
secretion  of  the  liquor  amnii.  Others  describe  vasa  propria  as 
existing  in  the  amnion  in  the  neighbourhood  of  the  placenta  at  the 
early  stage  of  pregnancy,  and  consider  abnormal  persistence  of 
these  vessels  to  be  one  cause  of  hydrops  amnii. 

The  Liquor  Amnii. — The  amnion  is  at  first  close  to  the  back  of 
the  embryo,  but  it  gradually  becomes  distended  by  a  fluid,  the 
liquor  amnii,  until  it  is  brought  into  contact  with  the  chorion. 
Eelatively  to  the  foetus  the  amount  of  the  liquor  amnii  is  much 
greater  in^the  earlier  months  of  pregnancy,  at  which  time  the 
tetus  floats  quite  freely  in  it.  Its  actual  maximum  is  reached 
about  the  seventh  or  eighth  month,  after  which  it  is  in  part 
absorbed.  The  average  quantity  on  delivery  is  from  one  to  two 
pints,  1300  gr.  (Winckel).  The  amount  of  fluid  varies  greatly  in 
different  cases.  The  liquor  amnii  also  varies  in  specific  gravity, 
1004 — 1025,  the  average  being  from  1020  in  the  earlier  months  to 
1010  at  the  end  of  pregnancy.  It  is  a  yellowish  clear  or  dark  flaky 
fluid,  alkaline  or  neutral  in  reaction,  contains  salts,  chiefly  chlorides 
and  phosphates,  some  albumen,  more  in  the  earlier  months  than 
in  the  later,  and  urea  towards  the  end  of  pregnancy.  At  first  it 
is  quite  limpid  and  clear,  but  becomes  somewhat  more  turbid 
towards  the  end  of  pregnancy  from  the  foetal  lanugo,  epithelial 
scales,  and  vernix  caseosa  which  are  shed  into  it.  It  does  not 
normally  contain  bacteria  or  any  of  the  alvine  excretion  of  the 
foetus,  but  occasionally,  without  any  foetal  disease,  it  is  found  dark 
and  discoloured. 

Origin  of  the  Liquor  Amnii. — The  liquor  amnii  is,  in  considerable 
part,  derived  from  the  maternal  vessels  and  not  from  the  foetus. 
This  is  evident  from  cases  in  which  the  embryo  has  perished  at  a 
very  early  stage,  but  in  which,  nevertheless,  liquor  amnii  is  found 
to  be  present  in  proportion  to  the  size  of  the  ovum  and  not  to 
that  of  the  embryo,  which  in  some  instances  may  have  entirely 
disappeared.  The  process  must  be  one  of  transudation,  chiefly 
from  the  maternal  vessels  of  the  placenta ;  and  the  fact  that  the 
injection  of  potassium  iodide  into  the  maternal  circulation  is 
followed  by  its  appearance  in  the  liquor  amnii,  although  it  cannot 
be  recovered  from  foetal  kidneys,  is  in  favour  of  this  view.  It  is 
possible  that  the  determination  of  the  transudation  in  the  direction 
of  the  amnial  cavity  may  be  due  to  a  secreting  power  in  the  cells 
lining  the  amnion  ;  and  this  is  supported  by  the  evidence  of  certain 
observers  who  have  demonstrated  changes  in    the    cells    of    the 


88  The  Practice  of   Midwifery. 

amnion  suggestive  of  secretory  activity,  especially  in  cases  of 
hydramnion. 

It  is  probable,  however,  that  the  foetal  vessels  are  also  an  impor- 
tant source  of  the  liquor  amnii,  for  it  exists  in  oviparous  animals. 
The  amnion  itself  has  no  vessels,  but  a  system  of  capillaries  is 
described  starting  from  the  umbilical  cord  and  ramifying  on  the 
inner  surface  of  the  placenta,  just  under  the  amnion.  These 
become  atrojDhied  towards  the  end  of  pregnancy,  as  also  do  the 
vessels  already  described  (p.  87)  as  existing  in  the  mesenchyme 
between  amnion  and  chorion.  Some  notable  proj)ortion  also  of 
the  liquor  amnii,  especially  in  the  later  months  of  pregnancy,  may 
be  formed  by  the  urine  of  the  foetus,  which  is  discharged  into  it. 
This  seems  to  be  proved  not  only  by  the  presence  of  urea  in  the 
liquor  amnii,^  increasing  in  amount  towards  the  end  of  pregnancy, 
but  by  the  fact  that,  when  there  is  occlusion  of  the  urinary  passages 
of  the  fcetus,  the  bladder,  ureters,  or  pelves  of  the  kidneys  become 
distended  with  urine.^  In  such  instances  the  swelling  of  the  foetal 
abdomen  so  produced  sometimes  proves  a  serious  obstacle  to 
delivery,  and  necessitates  embrj^otomy.  It  is,  however,  by  no 
means  certain  that  the  foetus  discharges  urine  into  the  liquor  amnii 
in  normal  conditions ;  this  may  only  occur,  as  Winckel  believes, 
when  its  life  is  in  danger.  The  source  of  the  small  amount  of  urea 
usually  found  in  the  liquor  amnii  would  then  be  the  maternal 
blood.  The  increased  amount  of  urine  secreted  by  the  fcetus 
towards  the  end  of  pregnancy,  and  the  disappearance  of  the  capil- 
lary system  on  the  surface  of  the  placenta,  is  considered  to  explain 
the  change  of  composition  in  the  liquor  amnii  in  the  later  months. 
The  proportion  of  albumen  may  diminish  from  about  "8  per  cent, 
to  "08  per  cent.,  while  that  of  urea,  which  in  the  early  months 
amounts  only  to  a  trace,  may  rise  to  '35  or  '4  per  cent. 

Uses  of  the  Liquor  Amnii. — The  liquor  amnii  provides  a  fluid 
medium  in  which  the  foetus  is  suspended,  and  which  protects  it 
both  from  shocks  or  pressure  from  without,  and  from  interference 
with  its  circulation  by  uterine  contractions.  It  also  gives  space 
for  those  muscular  movements  of  the  fcetus  which  are  doubtless  of 
importance  in  exercising  its  muscles  and  promoting  its  growth,  and 
prevents  the  formation  of  amniotic  adhesions.  In  labour  it  is  of 
great  service  by  forming,  with  the  protruding  bag  of  membranes,  a 

1  The  amount  of  urea  present  is  often  not  greater  than  that  usually  met  with  in 
serous  fluids,  viz.,  -03 — '04  per  cent. 

2  Joulin,  however  (Traitd  d'Accouchements,  p.  308),  denies  this  inference,  having 
collected  a  number  of  cases  in  which  there  was  occlusion  of  urethra  without  distension 
of  bladder,  and  considering  that  the  amount  of  urea  in  the  liquor  amnii  is  too  small  to 
justify  the  conclusion  that  the  urine  is  habitually  discharged  into  it, 


Early  Development  of   the  Ovum.  89 

fluid  wedge  which  dilates  the  cervix  and  os  uteri.  It  also  protects 
the  child  from  the  pressure  of  the  uterine  contractions  in  the  first 
stage  of  labour,  keeps  the  placenta  in  contact  with  the  uterine  wall, 
and  after  rupture  of  the  membranes  lubricates  and  cleanses  the 
genital  canal.  The  liquor  amnii  is  not  supposed  to  furnish  nutri- 
ment to  the  fcetus,  but  the  foetus  occasionally  swallows  some  of  it, 
as  is  proved  by  lanugo  and  epidermic  scales  being  found  in  the 
intestines.  Some  consider  that,  in  this  way,  the  liquor  amnii  serves 
a  purpose  in  providing  the  fcetus  with  water. 

The  Yolk-sac  or  Umbilical  Vesicle. — The  yolk-sac  is  at  first  large 
in  comparison  to  the  cavity  within  the  embryo,  and  for  a  time  the 
latter  derives  the  greater  part  of  its  nourishment  from  it.  As 
the  embryo  increases  in  age  it  soon  becomes  developed  out  of 
proportion  to  the  size  of  the  yolk-sac.  As  a  result  of  this  a  folding 
in  of  the  embryonic  area  occurs  around  its  margins,  especially 
anteriorly,  where  a  diverticulum  of  the  yolk-sac  is  formed,  the 
primitive  fore  gut.  The  folding  in  at  the  sides  and  the  tail  end 
occurs  somewhat  later,  but  is  ultimately  carried  out  so  that  the 
hind  gut  is  formed,  and  the  connecting  stalk,  now  bent  round  to 
the  ventral  aspect  of  the  embryo,  becomes  the  abdominal  stalk 
(Bauchstiel).  The  constricted  neck  of  the  yolk-sac  is  termed 
the  vitelline  duct,  and  its  expanded  extremity  is  the  umbilical 
vesicle. 

The  Allantois. — Before  the  folds  of  the  amnion  have  completely 
met,  the  formation  of  the  allantois  in  many  of  the  lower  mammals 
commences  by  a  depression  on  the  inner  side  of  the  entoderm, 
destined  to  form  the  lining  of  the  future  intestine.  This  depression 
carries  before  it  the  inner  of  the  two  layers  into  which  the  meso- 
derm has  become  divided,  so  as  to  form  a  projection  into  the  space 
between  the  two  layers,  or  the  coelom  {al  in  a,  b.  Fig.  59,  p.  83). 
The  allantois  thus  forms  at  first  a  hollow  vesicle,  its  cavity  opening 
into  the  lower  end  of  the  hind  gut.  The  vesicle  thus  formed, 
according  to  the  usual  description,  receives  two  arteries  and  two 
veins,  and  grows  out  rapidly  between  the  yolk-sac  and  the  amnion 
(pj9.  Fig.  59),  until  it  reaches  the  inner  surface  of  the  chorion 
(Fig.  59,  A,  b).  It  quickly  S23reads  over  this,  and  thus  performs  the 
important  function  of  conveying  to  it  a  vascular  supply  and  con- 
nective tissue  substratum.  The  expanding  allantois  with  its 
tubular  pedicle  has  been  compared  to  an  umbrella  with  its  handle. 
In  some  lower  mammals  the  vesicle  formed  by  the  allantois 
projecting  into  the  coelom  serves  as  a  receptacle  for  the  urinary 
secretion  at  an  early  stage  of  development.     In  birds,  the  allantois 


90 


The  Practice  of   Midwifery. 


has    a    considerable    development    and    a    prolonged    use,    as    it 
completely  envelops  the  yolk-sac. 

In  man  and  the  monkeys  theallantois  appears  at  a  comparatively 
late  stage  as  a  hollow  diverticulum  from  the  yolk-sac  growing  into 
the  middle  of  the  mesoderm  of  the  connecting  stalk.  It  is  an 
unimportant  structure,  and  does  not  vascularise  the  chorion,  which, 
indeed,  it  never  reaches,  and  the  greater  part  of  it  remains  merely 
as  a  relic.     When  the  umbilical  cord  is  formed  the  extra-embryonic 


Chorionic  villi 


Mesoderm 


Mesoderm- 


-Vessela 


Fig.  65. — Sagittal  section  of  early  human  ovum   2  mm.  in  length.     (After 
Graf  V.  Spee,  from  Volkmann's  Entwickelungsgeschichte). 

portion  of  the  allantois  is  found  embedded  in  it,  while  the  intra- 
embryonic  portion  forms  the  urinary  bladder  and  urachus. 

Formation  of  Bloodvessels. — The  first  appearance  of  blood- 
vessels is  to  be  seen  on  the  under-aspect  of  the  yolk-sac,  from  which 
they  gradually  extend  until  the  whole  is  covered  with  a  vascular 
network  (Fig.  65).  In  an  early  human  Ovum  of  about  eighteen  to 
nineteen  days'  development  (Eternod^)  the  two  heart  tubes,  still 

1  Eternod,  Anatom.  Anzeiger,  1899,  Vol.  XV.,  p.  181. 


Early  Development  of   the  Ovum.  91 

separate  from  one  another,  are  seen  to  be  portions  of  a  sinus-like 
vessel  which  runs  back  on  either  side  of  the  notochord  to  form  the 
primitive  aortas  and  passes  as  a  single  trunk  bhrough  the  connect- 
ing stalk  into  the  chorion.  Where  this  vessel  lies  near  the  mouth 
of  the  yolk-sac  it  is  joined  by  a  vascular  loop  surrounding  the 
allantoic  tube,  the  sinus  ensiforme,  into  which  the  vessels  from  the 
yolk-sac  pass.  It  is  obvious,  therefore,  that  at  a  very  early  stage 
of  development  indeed  in  the  human  ovum  a  circulatory  system  is 
established  between  the  embryo  and  the  chorion  (Bryce),  which  is 
of  great  interest  in  connection  with  the  functions  of  the  cells  of  the 
trophoblast.  At  a  later  stage,  after  the  complete  establishment  of 
the  vitelline  circulation,  as  in  an  ovum  described  by  His,  the  heart 
is  present  still  as  a  single  tube,  but  showing  a  division  into  an 
auricular,  ventricular,  and  bulbar  part,  and  is  joined  by  three  pairs 
of  veins :  the  vitelline  veins  from  the  yolk-sac,  the  allantoic  from 
the  chorion,  and  the  ducts  of  Cuvier,  formed  by  the  union  of  the 
cardinal  veins,  from  the  body  of  the  embryo. 


Chapter  IV. 
THE  CHORION,  PLACENTA,  AND   UMBILICAL  CORD. 

The  Chorion. — When  the  ovum  reaches  the  uterine  cavity  it 
has  no  doubt  attained  the  stage  of  an  early  blastocyst,  and  measures 
about  '2  mm.  in  diameter.  In  the  mouse  the  zona  peUucida  is  still 
present  at  this  stage,  but  quickly  disappears,  and  probably  in  the 
case  of  the  human  ovum  it  is  also  present  when  the  ovum  first 
reaches  the  uterus.  The  outer  epithelial  covering  of  the  blastocyst, 
the  trophoblast,  -which,  as  we  have  seen,  has  the  power  of  destroying 
the  maternal  tissues,  is  arranged  in  many  layers,  and  at  first  is 
composed  of  discrete  cells. 

The  ovum  generally  becomes  attached  to  the  surface  of  the 
mucous  membrane  on  the  posterior  or  anterior  wall  of  the  uterus 


Mesoblast. 

Trophoblast. 

Bloodspace. 

Syncytium. 

Endothelium. 

Capillary. 

Decidua. 


Uterine  wall. 


Fig.  66. — Development  of  placenta  (diagrammatic).     (After  Peters.) 


near  the  fundus,  most  frequently  on  the  posterior,  rarely  toward 
the  lower  part  of  the  cavity.  The  causes  which  determine  the  site 
of  attachment  are  unknown.  As  already  described  (see  pp.  72,  73), 
the  ovum  quickly  buries  itself  in  the  mucous  membrane,  which  at 
once  begins  to  become  converted  into  decidua,  and  forms  the 
elevation  which  is  the  characteristic  resting-place  of  all  the  four 
earliest  human  ova  yet  described  (Fig.  48,  p.  71). 


The  Chorion,  Placenta,  and  Umbilical  Cord.     93 

By  a  process  of  necrosis  followed  by  solution  a  large  implantation 
cavity  is  formed  in  the  decidua,  in  which  the  ovum  at  first  lies  free. 
Very  rapid  proliferation  now  ensues  in  the  trophoblast,  which  shows 


a  differentiation  into  a  cellular  layer,  the  cyto-trophoblast,  imme- 
diately surrounding  the  ovum,  and  a  layer  of  undifferentiated 
protoplasm,  the  plasmodi-trophoblast,  which  throws  out  numerous 
buds,  and  in  large  part  fills  up  the  implantation  cavity.     The  power 


Syncytium. 


Fibrin. 
Capillar3^   ~  ~  -4' 


Mesoblast. 


Trophoblast. 

Decidua. 
Fibrin. 

Blood  space. 
Decidua. 


Fig.  68. — Development  of  placenta  (diagrammatic).     (After  Peters. 

of  destroying  the  maternal  tissues  resides  mainly  in  the  plasmodi- 
trophoblast. 

As  the  maternal  tissue  is  dissolved,  both  bloodvessels  and  glands 
are  eroded  (Figs.  66,  68),   and  thus   spaces  are  formed,  bounded 


'  Graf  V.  Spec,  Zeit.>^chr.  f.  Morphol.,  Bd.  :-5,  1!)01,  s.  i:5U. 


94 


The  Practice  of   Midwifery. 


partly  by  decidual  tissue  and  partly  by  trophoblast,  which  become 
filled  by  maternal  blood  owing  to  the  erosion  of  the  vessels.  Other 
S]paces  are  formed  by  vacuolation  in  the  midst  of  the  plasmodi- 
trophoblast  itself,  which  eventually  communicate  with  those  of  the 


=■•..«  .•"2  ^--^ 


'o      „       »      ® 

^    1       a    o 


• '   !;-#^^ 

Fig.  69. — Vertical  section  through  the  decidua  basalis  at  the  sixth  week, 
showing  the  penetration  of  the  villi  into  the  decidua.  D,  decidua ; 
V,  section  of  villus  embedded  in  a  haemorrhage  ;  h,  haemorrhages;  e  b, 
epithelial  buds,  from  other  embedded  villi,  not  shown  in  the  section ; 
a,  bud  showing  section  of  vessel  in  its  interior.     (After  Eden.) 

former  variety,  and  become  also  filled  with  maternal  blood.  These 
sjDaces  form  the  commencement  of  the  maternal  blood  space  of  the 
placenta.  The  blood  in  them  does  not  coagulate,  but  serves  to 
nourish  the  ovum. 

They  are  thus,  according  to  the  modern  view,  extra- vascular  from 
the  commencement,  and  not  formed  by  dilatation  of  the  maternal 
vessels,  as  was  formerly  held  by  many  anatomists. 
A  sluggish  circulation  takes  place  through  them ; 
and  the  eroded  maternal  vessels  opening  into  them 
become  hypertrophied,  and  eventually  form  the 
maternal  arteries  and  veins  communicating  with 
the  general  intervillous  blood- space  of  the  placenta, 
in  which  the  maternal  circulation  then  becomes 
thoroughly  established. 
The  ovum  now  becomes  fixed  to  the  decidua  first 
by  strands  of  plasmodi- trophoblast  and  then  by  the  chorionic  villi 
(Fig,  71).  The  implantation  cavity  at  this  stage  forms  a  definite 
space  in  which  the  ovum,  surrounded  by  its  trophoblastic  processes, 
lies  bathed  in  the  maternal  blood  and  attached  to  the  walls  of  the 


Fig.  70.— Very 
early  human 
ovum,  of  date 
not  exceed- 
ing fourteen 
days.  (After 
Velpeau.) 


The  Chorion,  Placenta,  and  Umbilical  Cord.     95 

cavity  by  the  tips  of  the  processes.  All  round  the  ovum  the  decidua 
lining  the  cavity  is  in  a  condition  of  advanced  coagulation  necrosis, 
appearing  as  a  darkly  staining  zone  with  no  nuclei  and  studded 
with  leucocytes. 

Soon  the  irregular  masses  of  trophoblast  are  penetrated  with 
buds  of  connective  tissue  growing  out  from  the  mesoderm  of  the 
chorion  (Fig.  68).  These  branch  and  penetrate,  like  a  core,  the 
processes  of  trophoblast,  thus  converting  them  into  villi  (Fig.  68). 

•  *  *  vp ' ,'  *,  •  t '  *  ^  1  -  V  ,'  '  ^- '  '  ,  •  "■  ■"■  >4®J^  ~  «*  *  • '  *  *'*.*  •••* 

'**<i^  ^ .  •      <}  '.       *'    }■'*'    '  ji^' '.'."''  • ' '  '  •    ,'t>'- ^  '  I '  •  ft  *  •  * 


i*^ 


*  »  •   *     * 

Fig.  71. — Diagram  of  Teacher-Bryce  ovum,  13  to  14  days  old.  (Modified.)  The 
cavity  of  the  blastocyst  completely  filled  by  mesoderm,  and  imbedded 
therein  are  the  amnio-embryonic  and  entodermic  vesicles.  The  cyto-tropho- 
blast  forms  the  outer  covering  of  the  blastocyst,  and  a  network  of  plasmodi- 
trophoblast  unites  it  to  the  walls  of  the  implantation  cavity.  The  necrotic 
zone  of  the  decidua  is  seen,  and  here  and  there  masses  of  plasmodium 
invading  the  capillary  vessels  in  the  decidua.  Scattered  throughout  the 
decidua  are  small  glands  and  numerous  vessels  lined  by  endothelirmi.^ 

As  soon  as  the  foetal  vessels  reach  the  chorion  they  begin  to  spread 
over  the  whole  surface  of  it,  and  penetrate  the  connective-tissue 
core  of  the  villi,  thus  rendering  them  vascular.  The  fcetal  tropho- 
blast of  the  villi  becomes  arranged  in  two  layers — an  inner  layer  of 
cells,  or  Langhans'  layer,  and  an  outer  layer  of  undifferentiated 
protoplasm  or  syncytium  (Figs.  66,  68).  Peters  thought  that  the 
conversion  off  the  surface  layer  of  the  epithelium  into  syncytium 
was  due  to  the  action  of  the  maternal  blood,  but  it  is  probable  that 
it  is  developed  at  even  an  earlier  stage  than  this,  and  it  is  derived 
from  the  plasmodi-trophoblast.     The  villous  stems  are  at  first  single, 

'  Eai-Iy  JJevelopment  and  Imbedding  of  the  Human  Ovum,  1908. 


96 


The  Practice  of   Midwifery. 


but  they  soon  become  divided  up  into  numerous  branches,  and  in 
the  capillary  vessels  in  their  interior  nucleated  blood  corjDuscles  can 
be  seen  derived  from  the  embryo,  and  carried  to  the  villi  by  the 
allantoic  arteries  through  the  abdominal  stalk. 

In  the  first  few  weeks  of  pregnancy  the  whole  surface  of  the 
ovum  becomes  surrounded  with  branching  vascular  villi,  which 
come  into  relation  with  the  decidua  reflexa  as  well  as  the  decidua 
vera.  Spaces  containing  maternal  blood  thus  surround  the  whole 
ovum  (Fig.  71).  As  joregnancy  advances,  the  blood  supply  of 
the  decidua  basalis  increases,  and  that  of  the  decidua  capsularis 
diminishes.       The    villi    in    relation    with    the    decidua    basalis 

multiply  rapidly  and  form  the  chorion 
frondosum,  which  eventually  becomes 
the  placenta.  Over  the  rest  of  the 
ovum  the  villi  grow  less  rapidly 
(Fig.  72),  and  eventually  atrophy,  and 
their  vessels  disappear.  This  part  of 
the  chorion  is  then  known  as  the 
chorion  loeve.  By  the  time  the  decidua 
capsularis  has  come  in  contact  with 
the  decidua  vera,  at  some  time  in  the 
fourth  month  of  pregnancy,  the  blood 
spaces  of  the  former  have  shrunk  up 
and  disappeared,  and  the  villi  are 
atrophied  and  evascular.  In  a  section 
through  the  membranes  in  situ  in  the 
later  months  of  pregnancy,  a  layer  of 
foetal  epithelium,  several  cells  deep,  is 
seen  outside  the  connective  tissue  of 
the  chorion,  and  in  it  a  few  sections  of 
atrophic  villi,  not  containing  vessels.  Outside  this  is  a  layer  of 
fibrin-like  material,  containing  small  spaces,  which  is  considered  to 
arise  from  degeneration  of  fcetal  and  decidual  cells.  It  is  known 
as  the  canalised  fibrin,  or  Nitabuch's  fibrin  layer,  and  is  believed  to 
indicate  the  demarcation  between  foetal  and  maternal  tissue. 


Fig.  72. — Human  ovum  of  eighth 
week  :  the  growth  of  villi 
preponderates  at  one  part ; 
at  other  parts  the  villi  are 
already  becoming  atrophied. 
(After  Carpenter.) 


The  Placenta. — A  placenta  consists  essentially  of  two  vascular 
structures,  one  maternal  and  one  foetal,  so  closely  interlocked 
together  that,  without  any  actual  communication  between  the  two 
vascular  systems,  interchange  of  gases  and  of  nutritive  and 
excretory  material  can  take  place  between  them. 

Varieties  of  Placenta  in  Animals. — In  the  simpler  forms  of 
placenta   found  in  animals,  such  as  the  diffused  placenta  of   the 


The  Chorion,  Placenta,  and  Umbilical  Cord.     97 

mare,  or  the  polycotyledonary  placenta  of  ruminants,  depressions 
or  crypts  more  or  less  complex  are  formed  by  the  developing 
maternal  mucous  membrane,  into  which  are  inserted  tufts  of 
chorionic  villi.  These  crypts  are  not  the  enlarged  mouths  of  the 
uterine  glands,  as  was  formerly  supposed  by  some ;  but,  on  the 
contrary,  the  gland-tubes  more  frequently  open  on  the  ridges 
between  the  crypts,  or  on  part  of  the  mucosa  not  in  contact  with 
villi.     The  mode  of  their  formation  appears  to  be,  that  when  one  of 


Fig.  73. — Diagram  of  embedding  of  early  human  ovum.i  y^j,  fibrin  cap  ; 
tr\  trophoblast  ;  em.  embryo ;  gl.  glands ;  v.  vessels  of  uterus  ; 
m.  muscle  of  uterine  wall ;  cIl.  early  chorion. 


the  earliest  villi  has  attached  itself  to  the  uterine  mucous  mem- 
brane, the  membrane  grows  up  into  a  ridge  around  it.^  As  the 
villus  develops  into  a  tuft,  the  crypt  which  is  thus  formed  becomes 
more  and  more  complex.  The  crypts  have  an  epithelial  lining,  and 
the  villi  likewise  have  an  epithelial  covering.  Between  the  two  a 
small  quantity  of  albuminous  fluid  can  be  detected,  secreted  by  the 
epithelium  of  the  mucous  membrane,  which  thus  discharges  a  kind 
of  glandular  function.  To  this  fluid  the  name  of  "  uterine  milk" 
has  been  applied,  and  it  is  to  its  absorption  by  the  villi  that  the 

1  Peters,  Verhand.  d.  Deut.  Gesellsch.  f.  Gynak.,  1897,  Vol.  VH.,  s.  264. 

2  See  Lectui-e.s  on  the  Comparative  Anatomy  of  the  Placenta,  by  Professor  Turner, 
E.linburgh,  1S7G. 

M.  7 


98 


The  Practice  of  Midwifery. 


fcetus  owes  its  nourishment.  When  delivery  takes  place,  the  villi 
are  drawn  out  of  the  crypts,  like  fingers  out  of  a  glove,  and  bring 
away  with  them  either  no  maternal  tissue,  or  only  some  of  the 


—  Foetal  vessel. 

Main  trunk 
of  chorionic 
villi. 


Chorionic  villi. 


Maternal 
vessel. 

"Uterine  wall. 


Fig  74. — Section  through  placenta  of  seven  months  i«  ^i^M.     (Af ter  Minot.) 

epithelium.     No    bleeding    therefore   takes   place,    as   a   rule,    in 
parturition.     Such  forms  of  placentae  are  called  non-deciduate. 

In  deciduate  placentae,  such  as  the  zonary  placentae  of  carnivora, 
the  interlocking  of  the  two  membranes  is  more  complex,  so  that 


The  Chorion,  Placenta,  and  Umbilical  Cord.     99 

they  cannot  be  separated  in  parturition.  The  ridges  of  maternal 
mucous  membrane  not  only  grow  up  perpendicular  to  the  surface, 
but  send  off  partitions  or  trabeculse  at  various  angles,  and  the  villi 
are  divided  into  more  complicated  branching  tufts.  More  or  less 
of  the  maternal  laminae  is  then  torn  away  in  parturition,  or  on 
artificial  separation  of  the  placenta,  remaining  in  the  fissures 
between  the  foetal  portions  of  the  placenta,  and  the  maternal  vessels 
are  thereby  ruptured.  In  some  cases  a  more  or  less  continuous 
layer  of  mucous  membrane,  forming  a  decidua  basalis  correspond- 
ing to  that  in  the  human  subject,  is  also  brought  away  in  parturition 
on  the  uterine  surface  of  the  placenta.  In  this  form  of  placenta, 
as  in  the  simpler  kind,  a  maternal  epithelium  covers  the  laminse  or 


Fig.  75. — Diagram  of  mode  of  attachment  of  villi  to  the  decidua,  showing 
proliferation  of  cells  of  Langhans'  layer,  and  spreading  of  syncytium  over 
the  surface  of  the  decidua. 


trabeculse  of  maternal  mucous  membrane,  called  decidual  processes, 
and  intervenes  between  the  maternal  vessels  and  the  villi.  Pro- 
fessor Turner  describes  an  early  stage  of  enlargement  of  maternal 
vessels  into  sinus-like  spaces  as  visible  in  some  parts  of  the  placenta 
of  the  cat.  In  that  of  the  fox,  he  finds  the  capillaries  dilated  to 
from  twice  to  four  times  the  capacity  of  the  fcetal  capillaries,  and 
in  that  of  the  sloth  he  describes  a  still  more  remarkable  dilatation 
of  vessels,  no  maternal  capillaries  at  all  existing,  and  all  the  maternal 
vessels  being  of  colossal  size,  as  compared  with  capillaries. 

Developnent  of  Human  Placenta. — According  to  the  modern  view, 
the  formation  of  the  placenta  in  man  and  monkeys  is  totally  different 
from  its  formation  in  the  lower  mammals ;  since  the  ovum  burrows 
at  once  into  maternal  tissue  (see  p.  72),  and  the  placenta  is  formed 
entirely  within  the  substance  of  the  uterine  mucous  membrane. 

7—2 


lOO 


The  Practice  of   Midwifery. 


The  earlier  stages  have  ah-eady  been  described  (pp.  72 — 73).  As 
the  decidua  basalis  develops,  its  deepest  part  becomes  converted,  like 
the  decidua  vera,  into  two  layers,  a  spongy  or  ampuUary  layer  con- 
taining the  dilated  gland  cavities,  next  to  the  muscular  wall  (Fig.  74), 
and  within  this  a  compact  layer,  constituted  by  the  characteristic 
decidual  cells.  A  considerable  number  of  the  primary  villi  extend 
from  the  chorionic  membrane  to  the  compact  layer  of  the  decidua, 
to  which  their  extremities  are  attached.  These  are  termed  fastening 
villi  (Fig.  75),  and  form  the  main  framework  of  the  placenta. 
The  trophoblast  at  their  extremities  sends  out  processes,  composed 


..*!«»««-- 


w 

Syncytium.  #• 

Langhans'  layer. 


Stroma 


.»■■>'  -•*''*';V-.. 


"••1«t 


— '    Syncytium. 

Langhans'  layer. 


-t 


Stroma. 


Syncytium 


v.v^^w 


^'^■^^^^^■m.^^'''' 


Fig.  76, — Chorionic  villi,     a,  at  three  weeks  ;  B,  at  three  months  ;  C,  at  nine 
months.     (After  Whitridge  Williams.) 


of  proliferating  cells  of  Langhans'  layer,  which,  like  the  roots  of  a 
tree,  invade  the  deeper  decidual  tissue,  the  so-called  cell  nodes  or  cell 
columns,  and  thus  unite  the  placenta  firmly  to  the  uterine  wall. 

The  main  mass  of  the  placenta  is  made  up  by  the  prolifera- 
tion of  villi,  which  project  freely  into  the  blood  spaces.  When 
teased  out  they  form  a  mass  like  very  fine  seaweed  branching 
from  main  trunks  attached  to  the  chorionic  membrane  (see 
Fig.  72,  p.  96). 

Only  the  fastening  villi  are  attached  to  the  decidua  basalis,  but 
occasionally  the  extremity  of  a  terminal  villus  may  be  attached  by 
a  band  to  a  neighbouring  villus.  An  artery  and  vein  enter  each 
villus.      In  the  longer  branches,  connecting  vessels  run  between 


The  Chorion,  Placenta,  and   Umbilical  Cord.      loi 

the  artery  and  vein,  forming  a  fine  capillary  network.  In  the 
smallest  terminal  twigs  there  may  be  only  a  single  vascular 
loop.  In  the  later  months  of  pregnancy,  the  vessels  in  the  ultimate 
branches  of  the  villi  are  large  in  proportion  to  the  size  of  the  villus, 
and  occup}^  nearly  its  whole  substance.  By  increasing  proliferation, 
the  small  villi  become  more  numerous  in  proportion  to  the  large 
main  trunks  as  pregnancy  advances. 

The  stroma  of  the  chorion  and  chorionic  villi  is  a  connective  tissue 
of  characteristic  appearance,  but  varies  according  to  the  stage  of 
pregnancy.  In  the  earlier  weeks  the  cells  are  stellate  and  branching 
and  are  separated  from  one  another  by  a  considerable  amount  of 
mucoid  substance  (Fig.  76,  a).  Later  they  become  more  spindle- 
shaped  and  more  closely  packed  together,  so  that  the  stroma  has  a 
denser  appearance  (Fig.  76,  c).  They  are  still  connected  by  fine 
fibrillar  processes,  which  distinguish  the  f cetal  connective  tissue  from 
the  maternal. 

In  the  first  three  months  of  pregnancy  a  double  layer  of 
epithelium  may  be  demonstrated,  covering  the  villi  and  all  other 
parts  of  the  chorion.  After  the  mid-term  of  gestation  the  deep 
layer  disappears  more  or  less  completely.  In  a  full-term  placenta 
even  the  superficial  layer  has  disappeared  from  some  of  the  villi, 
and  the  foetal  capillaries  are  separated  from  the  maternal  blood 
space  only  by  a  delicate  layer  of  connective  tissue. 

The  outer  layer  consists  of  the  syncytium,  a  thin  layer  of  granular 
multi-nucleated  protoplasm,  which  stains  deeply.  The  deep  or 
Langhans'  layer  consists  of  discrete  cells,  which  are  large  and  well 
defined,  with  oval  nuclei  standing  with  their  long  axes  at  right 
angles  to  the  surface. 

It  was  formerly  supposed  by  some  that  the  outer  layer  of 
epithelium  was  derived  from  the  mother ;  by  others  that  the 
deep  layer  belonged  to  the  fcetal  mesoderm,  and  was  not  really 
epithelial.  It  is  now  generally  agreed  that  both  layers  are  derived 
from  the  foetal  -epiblast.  It  is  probable  that  these  two  varieties 
of  the  trophoblast  are  more  or  less  convertible  one  into  the  other. 
Thus  the  primary  covering  of  the  ovum  is  cellular,  the  cyto- 
trophoblast,  and  this  becomes  converted  into  the  plasmodi-tropho- 
blast  or  syncytium.  A  section  of  an  early  ovum  often  shows 
masses  of  discrete  cells  connected  with  the  villi  but  outside  the 
syncytium,  and  a  continuity  between  them  and  Langhans'  layer 
can  only  occasionally  be  traced.  Intermediate  conditions  are  also 
seen,  in  which  the  separation  of  the  protoplasm  into  cells  is  only 
just  discoverable.  Again,  the  processes  from  the  ends  of  the 
fastening  villi  into  the  deep  layer  of  the  decidua  consist  of  discrete 


I02 


The  Practice  of   Midwifery. 


cells,  derived  from  Langhans'  layer ;  but  in  the  later  months 
of  pregnancy,  and  especially  in  the  last  month,  a  section  of  the 
decidua  basalis  shows  also,  in  its  superficial  portions,  fine  processes 
of  syncytium  mixed  up  with  the  decidual  cells. 

During  the  early  months  of  pregnancy  the  syncytium  of  the  villi 
shows  great  activity.  Proliferation  occurs  in  localised  areas,  result- 
ing in  the  formation  of  epithelial  buds  (Fig.  77),  which  are  the 
commencement  of  new  villi.  The  chorionic  stroma,  followed  by 
the  vessels,  only  enters  the  bud  later  (Fig.  77,  b),  and  Langhans' 
layer  of  cells  takes  no  part  in  the  formation  of  buds.  This 
dependence  of  the  proliferation  of  the  villi  upon  the  syncytium 
is  a  proof  that  the  S3aicytium  is  of  fcetal  and  not  of  maternal 
origin. 

A  section  of  the  placenta  in  the  fourth  month,  when  it  is  first 

full}'  constituted,  shows  that 
the  main  part  of  it  is  made 
up  of  chorionic  villi,  having 
still,  in  great  part,  their 
double  epithelial  covering. 
There  is  a  much  greater 
proportion  than  in  the  later 
months  of  large  chorionic 
trunks,  in  which  the  amount 
of  stroma  is  large  in  propor- 
tion to  the  vessels.  There 
are  many  processes  of  syncy- 
tium or  epithelial  buds  (see 
Fig.  69,  p.  94),  which  on 
section  look  like  giant  cells  lying  in  the  blood  sj^aces.  There  are  also 
masses  of  large  discrete  cells.  These  have  been  termed  "  decidual 
islands,"  and  have  been  considered  to  be  sections  of  decidual  pro- 
cesses extending  through  the  whole  thickness  of  the  placenta.  Many 
authorities,  however,  now  regard  them  as  masses  of  trophoblast, 
corresponding  in  structure  to  Langhans'  layer,  which  have  not 
been  penetrated  by  the  chorionic  connective  tissue,  and  therefore 
have  not  been  converted  into  villi.  Hence  the  tendency  is  now  to 
infer  that  decidual  processes  only  extend  for  a  very  short  way 
into  the  placenta  between  its  lobes,  and  that  the  rest  of  its  frame- 
work is  of  fcetal  origin. 

As  the  placenta  grows  the  intervillous  blood  spaces  expand  and 
communicate  more  and  more  with  each  other,  until  there  is  one 
general  blood  space  throughout  the  entire  placenta  filled  with 
maternal  blood,  in  which  the  chorionic  villi  hang  freely.      The 


Fig.    77.- 


fiom    an 


—A,  B,  Sections   of  villi 
ovum  at  the  sixth  week. 
Ves,  vessel ;  Up.  B,  epithelial  bud  ;  st,  stioma 
of  villus  ;  .«Z,  superficial  laj'erof  epithelium. 
The  deep  layer  is  not  seen.     (After  Eden.) 


The  Chorion,  Placenta,  and  Umbih'cal  Cord.      103 

maternal  arteries  and  veins  mostly  open  directly  into  this  through 
the  compact  layer  of  decidua  basalis.  There  are  no  maternal 
capillaries  in  the  placenta,  and  no  maternal  vessels  extend  more 
than  a  very  short  way  into  it,  along  the  decidual  processes.  In 
general,  the  veins  open  directly  by  an  oblique  course  (see  Fig.  74, 
p.  98),  through  the  decidua  basalis.  Some  of  the  arteries  open  on 
the  decidual  processes,  which  extend  a  short  way  into  the  placenta 
from  the  maternal  surface.  The  arteries  have  a  spiral  course  both 
through  the  muscular  wall  of  the  uterus  and  the  decidua  serotina. 
The  veins  are  destitute  of  true   valves,  but  they  are  often  bent 


Fig.  78. — Section  of  fully-formed  placenta,  with  part  of  the  nterus. 
a,  umbilical  cord  ;  h,  h,  section  of  uterus  ;  c,c,  c,  branches  of  the  umbilical 
vessels  ;  d,  d,  cuiiing  arteries  of  the  uterus. 


acutely  upon  themselves,  forming  what  is  described  as  a  falciform 
valve.  Thus  both  arteries  and  veins  are  closed,  after  separation 
of  the  placenta,  by  firm  contraction  and  retraction  of  the  uterine 
muscle. 

Chai'acters  of  the  full-grown  Placenta. — The  placenta  at  full 
term  forms  a  round  or  slightly  oval  mass,  of  spongy  consistency. 
Its  greatest  diameter  is,  on  the  average,  from  7  to  8  inches,  its 
greatest  thickness  about  an  inch,  and  its  weight  about  20  ounces. 
It  is  generally  inserted  on  the  posterior  or  anterior  wall  of  the 
uterus  near  the  fundus,  more  frequently  on  the  posterior.  More 
rarely  it  is  inserted  on  one  side,  and  if  so,  more  frequently  on  the 
right,   seldom  absolutely  on  the  fundus.     Still  more  rarely  it  is 


104 


The  Practice  of   Midwifery. 


inserted  lower  down  in  the  body  of  the  uterus,  either  approaching 
to  or  overlapping  the  internal  os.  Such  modes  of  insertion  imply 
respectively  the  risk  or  the  certainty  of  haemorrhage  before 
delivery,  and  will  be  discussed  under  the  head  of  placenta  praevia. 
The  placenta  is  never  inserted  upon  any  part  of  the  cervix.  The 
fcetal  or  internal  surface  of  the  placenta  is  smooth,  and  covered  by 
the  amnion,  which  can  be  easily  peeled  off  up  to  the  insertion  of 
the  funis,  or  for  about  half-an-inch  on  to  the  funis.  The  umbilical 
cord  is  generally  inserted  to  the  foetal  surface  a  little  excentrically, 
and  the  amnion  is  reflected  over  it.  Through  the  amnion  large 
arteries  and  veins  may  be  seen  radiating  over  the  surface  from  the 


ChAm 


Fig.  79. — Diagrammatic  section  of  placenta.  Am,  amnion;  Ch,  chorion; 
m,muscular  wall  of  uterus;  «r,  ampullarylaj'er  ;  V,  main  trunk  of  chorionic 
villi  ;  L,  lacuna  containing  maternal  blood  ;  s,  portions  of  maternal  tissue 
belonging  to  decidua  basalis  (?)  ;  cj,  glandular  spaces  ;  v,  vessel.  (After 
Leopold.) 


insertion  of  the  cord  (Fig.  81,  p.  106).     The  edges  of  the  placenta 
are  continuous  with  the  chorion  and  decidua  vera. 

The  external  or  maternal  surface  of  the  placenta,  somewhat 
convex,  is  slightly  rough,  compared  with  the  internal  surface,  and 
is  also  soft  and  friable.  It  is  covered  by  a  very  thin  greyish-white 
layer,  not  more  than  ^-^  inch  in  thickness,  formed  by  the  decidua 
basalis.  This  is  pierced  by  the  openings  of  the  arteries  and  veins 
passing  between  the  uterus  and  the  placenta.  It  may  be  torn  off 
in  places,  showing  the  redder  chorionic  villi  through  the  gaps.  It 
cannot  be  stripped  off,  except  in  small  pieces,  owing  to  the  firm 
attachment  to  it  of  the  chorionic  villi  beneath.  This  external 
surface  is  divided  by  numerous  sulci  into  lobes  called  cotyledons. 
The  layer  of   decidua   basalis  dips  down  into  the  sulci,  where  it 


The  Chorion,  Placenta,  and  Umbilical  Cord.      105 

is  continuous  with  the  decidual  processes,  which  extend  a  short 
distance  into  the  j)lacenta  between  its  lobes.  In  general  to  the 
centre  of  each  cotyledon  corresponds  a  main  branch  of  an  umbilical 
artery,  which  suddenly  dips  down  at  right  angles  from  the  foetal 
surface,  in  a  main  chorionic  trunk  (such  as  v.  Fig.  79,  p.  104).  It 
may  be  inferred  that  each  cotyledon  corresponds  to  the  develop- 
ment of  a  primary  chorionic  villus.  It  is  now  considered  that  the 
framework  of  the  placenta  is  made  up,  not  by  decidual  processes. 


\ 


\  ^^^': 


Fig.  80. — Uterine  surface  of  placenta. 

but  by  the  primary  main  trunks  of  villi  growing  from  the  chorion 
and  attached  ultimately  by  fastening  vilH  to  the  decidua  basalis. 
The  uterine  arteries  generally  enter  at  the  intersection  of  sulci, 
and  open  at  once,  or  after  a  very  short  course,  into  the  placental 
blood  spaces.  In  their  course  through  the  decidua  basalis  or, 
for  a  short  distance,  in  the  decidual  processes  between  the 
cotyledons,  they  are  destitute  of  muscular  walls,  and  differ  but 
slightly  from  veins.  The  openings  for  veins  are  situated  on  the 
sulci,  or  on  the  surface  of  lobes.  There  is  also  generally  described 
a  large  sinus,  the  circular  or  marginal  sinus,  into  which  many  of 


io6 


The  Practice  of   Midwifery. 


the  venous  apertui-es  open,  belonging  to  the  decidua  vera,  and 
running  round  the  placenta.  This,  however,  is  not  constant  in  its 
presence,  nor  does  it  completely  surround  the  placenta. 

A  certain  number  of  the  ramifying  branches  of  the  chorionic 
villi  run  pretty  direct  toward  the  decidua  basalis,  to  which  they 
are  firmly  attached.  In  this  way  the  two  surfaces  of  the  placenta 
are  held  together.  The  main  bulk  of  the  tissue  is  made  up  by  the 
exuberant  growth  of  the  lateral  branches  which  spring  from  these. 
The  terminal  twig  of  the  umbilical  artery  in  each  villus  bends  down 


Fig, 


81. — Foetal  siu'face  of  placenta.     Amnion  stripped  from  one  half  and 
removed. 


in  a  loop  to  become  the  efferent  vein.  It  is  said,  however,  that  the 
efferent  vessel  of  one  terminal  villus  may  become  the  afferent  vessel 
of  another.  Numerous  capillary  networks  also  exist  between  arteries 
and  veins  in  the  larger  trunks,  and  anastomoses  between  the  arteries. 
Near  the  margin  of  the  placenta  are  found  villi  in  which  there  is 
little  or  no  vascular  development,  but  which  retain  their  solid 
cellular  character. 

If  a  section  be  made  through  the  uterus  with  the  placenta  in  situ, 
there  is  seen  to  be  a  layer  of  the  decidua  basalis  just  beneath  the 
placenta,  in  which  large  flattened  spaces  are  developed.  This 
corresponds  to  the  "  areolar  or  ampullary  layer "  in  the  decidua 
vera,  and,  like  it,  forms  the  surface  of  separation  at  full  term  {ar, 


The  Chorion,  Placenta,  and  Umbilical  Cord.      107 

Fig.  79,  p.  104).  There  is  no  layer  of  maternal  tissue  over  the 
basement  chorion  from  which  the  main  trunks  of  the  chorionic  villi 
spring,  but  at  the  margin  of  the  placenta  a  portion  of  the  decidua 
basalis  can  be  traced  running  in  beneath  the  chorion  and  serving 
both  to  attach  the  placenta  to  the  uterine  wall  and  to  close  in  the 
intervillous  spaces  at  the  circumference. 

Here  and  there,  however,  small  areas  of  tissue  may  be  seen  on  the 
surface  of  the  chorion  or  surrounding  some  tufts  of  villi,  which  are 
regarded  by  some  authorities  as  consisting  of  maternal  tissue 
belonging  to  the  decidua  serotina,  but  are  almost  certainly  undiffer- 
entiated portions  of  trojDhoblast. 

In  a  microscopic  section  the  villi  are  seen  to  be  much  more 
numerous  than  in  the  early  months,  but  smaller.  The  vessels 
occupy  a  much  larger  proportion  of  their  space  in  comparison  with 
cellular  tissue.  Their  epithelial  covering  consists  only  of  a  thin 
layer  of  syncytium,  and  Langhans'  layer  has  disappeared.  Much 
fewer  epithelial  buds  or  processes  of  syncytium  than  in  the  earlier 
months  of  pregnancy  are  seen.  Canalised  fibrin  is  seen  abundantly 
beneath  the  epithelium  of  the  chorionic  membrane.  It  is  also 
visible  in  a  thin  layer  in  many  villi,  immediately  beneath  the 
epithelium,  and  covers  the  superficial  portions  of  the  compact  layer 
of  the  decidua  basalis.  Many  of  the  arteries  show  signs  of 
obliterative  endarteritis  tending  to  the  closure  of  their  lumen. 

There  are  generally  some  infarcts  visible  on  the  uterine  surface 
of  the  placenta.  These  are  due  to  the  obliteration  of  the  correspond- 
ing arteries  of  the  chorionic  villi,  accompanied  by  atrophy  and 
degeneration  of  the  villi  and  death  of  the  epithelium.  This  in  its 
turn  is  followed  by  the  clotting  of  the  blood  in  the  corresponding 
intervillous  spaces  and  the  formation  of  fibrin.  In  this  manner 
numerous  grey  or  placental  infarcts  are  formed  throughout  the 
substance  of  the  placenta  as  full  term  approaches.  They  form 
conical  or  greyish  masses,  the  base  of  the  cone  being  on  the  uterine 
surface  and  varying  in  size  from  some  hardly  visible  to  the  naked 
eye  to  others  several  centimetres  in  diameter. 

Some  authorities  describe,  as  occurring  in  the  last  month  of 
pregnancy,  a  spontaneous  thrombosis  in  some  of  the  uterine  sinuses 
beneath  the  placenta,  associated  with  an  encroachment  on  the 
sinuses  by  a  proliferation  of  the  lining  membrane.  This  has  been 
thought  to  have  to  do  with  the  causation  of  the  onset  of  labour,  but 
is  not  yet  absolutely  proved  to  be  a  normal  occurrence. 

Functions  of  the  Placenta. — As  we  have  seen  in  considering 
the  structure  of   the  placenta,    the  foetal  blood  circulating  in  the 


io8  The  Practice  of   Midwifery. 

capillaries  of  the  chorionic  villi  is  separated  from  the  maternal 
blood  in  the  intervillous  spaces  by  the  connective  tissue  of  the 
villus,  the  endothelial  wall  of  the  capillary,  in  the  early  months  by 
the  two  layers  of  epithelium  on  the  surface  of  the  villus,  and  in  the 
later  months  by  only  one  layer  or,  in  some  instances,  where  the 
capillary  lies  exposed  on  the  surface  of  the  villus,  by  its  endothelial 
wall  alone. 

It  is  obvious  therefore  that  gaseous  interchanges  between  the 
blood  of  the  mother  and  of  the  foetus  and  the  passage  of  fluid 
substances  from  the  one  circulation  to  the  other  can  take  place  with 
great  facility. 

In  the  early  stages  of  development  before  the  circulation  through 
the  chorion  is  established  the  foetus  is  no  doubt  nourished  by  the 
cells  of  the  trophoblast.  It  is  possible  that  they  have  the  power  of 
exercising  a  selective  action,  and,  according  to  HerfT,  they  secrete  a 
substance  which  has  the  effect  of  preventing  the  coagulation  of  the 
blood  circulating  in  the  intervillous  spaces.  That  the  placenta  acts 
very  efficiently  in  j^romoting  the  nutrition  of  the  foetus  is  demon- 
strated by  the  marked  and  continuous  increase  in  its  size  which 
takes  place  during  the  whole  period  of  intra-uterine  life. 

(1)  Picspiration. — By  the  interchange  of  gases  between  the  foeta 
and  maternal  blood,  the  placenta  serves  as  the  respiratory  organ  of 
the  foetus,  and  the  blood  which  reaches  the  placenta  through  the 
umbilical  arteries  darkened  with  carbonic  acid  returns  oxygenated 
through  the  umbilical  vein,  and,  as  Zweifel  has  demonstrated, 
containing  oxyhsemoglobin. 

Since  the  foetus  has  but  little  loss  of  heat  to  supply,  the  amount 
of  oxygen  required  is  probably  not  very  great.  Nevertheless, 
experiments  on  animals  have  shown  that,  if  the  placental  circulation 
be  interrupted,  respiratory  movements  are  excited,  and  the  foetus 
shows  signs  of  asphyxia  in  a  few  minutes,^  and  the  same  thing 
occurs  if  the  funis  is  compressed  in  delivery.  The  foetus  is,  however, 
capable  of  being  restored  after  a  longer  duration  of  asphyxia  than 
an  air-breathing  animal  would  survive. 

(2)  Nutrition. — From  the  time  of  its  formation,  the  placenta  is 
the  sole  organ  of  nutrition  for  the  foetus,  and  it  is  probable  that 
the  epithelium  of  the  villi  has  a  selective  power  in  absorbing 
nutriment.  That  not  only  substances  in  solution,  but  small 
particles  such  as  microbes,  may  pass  from  one  circulation  to  the 
other,  is  proved  by  the  fact  that  zymotic  diseases,  such  as  small- 
pox, chicken-pox,  and    scarlet  fever,  are  communicated  in   some 

1  Zweifel,  "  Die  Respiration  des  Foetus,"  Arch.  f.  Gynaii.,  [X.  and  XII. 


The  Chorion,  Placenta,  and   Umbilical  Cord.      109 

cases  from  the  mother  to  the  fcetus ;  for  it  has  been  shown  that 
the  contagimn  of  siich  diseases  is  particulate. 

In  tuberculosis  of  the  mother,  the  disease  is  very  rarely  com- 
municated to  the  foetus.  Kiiss  has,  however,  shown  that  in 
animals  tubercle  bacilli  may  pass  to  the  foetus  from  the  mother  via 
the  placenta  ;  and  in  typhoid  fever  the  bacilli  have  been  found  in 
the  tissues  of  the  fcetus  in  quite  a  large  number  of  cases.^  In  most 
other  zymotic  diseases,  too,  such  as  pneumonia,  relapsing  fever, 
anthrax,  cholera,  septicasmia,  the  transmission  of  the  disease  has 
been  definitely  proved.  There  is  always  the  probability,  however, 
that  in  such  instances  the  "  barrier  action  "  of  the  placenta,  as  its 
property  of  arresting  the  passage  of  certain  substances  has  been 
termed,  may  have  been  in  abeyance  owing  to  the  fact  that  the 
mother  was  suffering  from  the  disease  in  question.  There  appears 
to  be  normally  no  passage  of  red  corpuscles  from  the  maternal 
to  the  foetal  circulation,  or  vice  versa.  Thus  the  nucleated  red 
corpuscles  of  the  foetus  are  not  found  in  the  maternal  blood  at  all. 
At  the  same  time  it  must  be  remembered  that  the  analyses  made 
by  Varaldo^  of  the  blood  of  the  umbilical  vein  and  arteries,  while 
furnishing  further  proof  of  the  nutritive  functions  of  the  placenta, 
also  show  that  there  are  more  white  corpuscles  in  the  blood  of  the 
vein  than  in  that  of  the  arteries.^ 

If  these  observations  are  correct,  we  must  conclude  that  white 
cells  pass  from  the  mother  to  the  foetus,  that  some  of  them  are 
retained  in  the  latter,  and  that  they  may  serve  in  their  passage  as 
carriers  of  nutrition.  The  parasites  of  malaria  have  not  been 
proved  to  pass  from  the  maternal  to  the  foetal  circulation,  although 
cases  have  been  recorded  in  which  the  foetus  has  been  born  with 
a  greatly  enlarged  spleen. 

In  experiments  on  animals  it  has  been  found  that  minute 
particles  of  cinnabar  passed  from  the  maternal  to  the  foetal 
circulation.^  The  same  has  been  found  in  the  case  of  Indian  ink, 
but  in  these  cases  there  may  have  been  rupture  of  vessels,  and 
more  recent  observations  have  given  a  negative  result. 

It  is  possible,  as  has  been  suggested,  that  albuminous  bodies 
may  pass  the  placenta  as  soluble  peptones,  the  epithelium  of  the 
villi  secreting  a  peptonising  ferment. 

Various  chemical  substances  administered  to  the  mother  have 

1  Speier,  "  Zur  Casuistik  ties  Placentaren  Ueberganges  der  Typhusbacillen  von  der 
MuUor  auf  die  Frucht,"  D.  I.,  Bieslau,  1897;  H.  T.  Hicks  and  Herbert  French, 
I^aiicct,  June  3rd,  1905  ;  Kiiss,  De  VR6T6(lit6  Parasitaire  de  la  Tuberculose  Humaine, 
Paris,  1898. 

2  Varaldo,  Arch,  di  Ostet.,  1900,  Vol.  VIL,  p.  72.3. 
8  Ileitz,  Centralbl.  f.  die  Med.  Wissensch.,  1868. 


I  lO 


The  Practice  of   Midwifery. 


been  detected  in  the  foetal  circulation,  but  it  is  only  those  which 
are  highly  diffusible,  such  as  chloroform,  alcohol,  and  iodide  of 
potassium,  which  pass  with  freedom.  Thus  opium,  or  its  alkaloids, 
may  be  administered  to  the  mother  in  considerable  doses  without 
destroying  the  foetus,  although  young  infants  are  highly  susceptible 
to  their  influence. 

(B)  Excretion. — It  has  been  shown  ^  that  the  foetus  maintains  a 
temperature  of  its  own  slightly  (about  0*9°  F.)  above  that  of  the 
surrounding  parts  of  the  mother,  and  hence  tissue  changes  must 
take  place  in  it  with  some  activity.     The  urea  and  probably  other 


Fig.  82.^Early  ovum,  of  about  ten  weeks,  in  the  Museum  of  Guy"s  Hospital, 
showing  the  straight  direction  of  the  vessels  of  the  cord. 


waste  products  are  chiefly  got  rid  of  through  the  placenta,  although, 
to  some  extent,  they  are  discharged  with  the  foetal  urine  into  the 
liquor  amnii  in  the  later  months  of  pregnancy.  Thus  urea  has 
been  detected  in  the  blood  of  the  placenta,  in  greater  proportion 
than  in  other  parts  of  the  maternal  circulation.  Hence  the 
placenta,  to  some  extent,  discharges  the  functions  of  the  kidneys 
during  foetal  life.  According  to  Claud  Bernard,  it  has  also  a 
glycogenic  function,  and  it  still  further  resembles  the  adult  liver 
in  its  power  of  storing  up  mineral  and  microbic  poisons.  These 
functions  are  probably  performed  by  the  epithelium  of  the  villi. 
Whether  the  placenta  furnishes  an  internal  secretion  to  the  foetus, 

1  Warster,  "  Beitrage  zur  Tocothermometrie,"  D.  J.,  Zurich,  1870. 


The  Chorion,  Placenta,  and  Umbilical  Cord.     1 1 1 

or,  as  some  authors  have  contended,  to  the  mother,  is  a  problem 
which  must  be  left  to  the  future  to  decide. 


The  Umbilical  Cord. — The  umbihcal  cord,  or  funis,  forms 
the  link  between  the  umbilicus  of  the  child  and  the  foetal  portion 
of  the  placenta.  When  fully  formed  it  contains  the  two  umbilical 
arteries  and  one  vein,  originally  the  left  vein,  and  the  remnant  of 
the  pedicle  of  the  umbilical  vesicle.  It  is  covered  by  a  sheath 
consisting  of  modified  foetal  slcin,^  and  the  main  part  of  its  bulk 
is  made  up  of  a  special  kind  of  embryonic  connective  tissue  called 
Wharton's  jelly.  This  is  composed  of  delicate  interlacing  fibrillffi, 
which  are  processes  extending  from  small  stellate  cells,  and  have 
large  interspaces  filled  with  gelatinous  muco-albuminoid  material 


Fig.  83. — Microscopic  section  of  Wharton's  jelly  showing  stellate  cells  and 
interlacing  fibrillse. 

(Fig.  83).  The  cells  and  fibres  tend  to  arrange  themselves  in  a 
concentric  fashion  round  the  three  vessels.  Similar  tissue  occurring 
in  morbid  growths  receives  the  name  of  myxoma. 

The  surface  is  covered  with  several  layers  of  stratified  epithelium 
resembling  the  skin  of  the  foetus  at  the  fourth  month  of  intra-uterine 
life,  and  continuous  with  the  skin  of  the  foetus,  about  1  cm.  from 
the  surface  of  the  abdomen.  The  thickness  of  the  cord  is  generally 
about  that  of  the  little  finger,  but  varies  considerably,  according 
to  the  amount  of  Wharton's  jelly  present.  The  average  length  of 
the  cord  is  about  21  to  22  inches,  but  it  may  be  as  long  as  70  inches 
or  as  short  as  3  inches.  In  cases  of  malformation  of  foetus,  with 
extroversion  of  abdominal  viscera,  the  cord  may  be  absent  altogether, 
the  fa^tus  being  in  contact  with  the  placenta.  Excess  of  length  is 
more  frequent  than  defect.     When  very  long  it  is  liable  to  form 

'  Foulis,  T]-ans.  Mcd.-Chir.  Soc.  Edin.,  1900,  Vol.  XIX. 


I  12 


The  Practice  of  Midwifery 


loops  roiiucl  the  neck,  limbs,  or  body  of  the  foetus.  Knots  may 
also  be  formed  in  it  when  the  fcetus,  while  small,  happens  to  pass 
through  a  loop,  but  these  are  rare.  If  a  knot  becomes  drawn  tight, 
the  fcetus  may  perish  from  the  arrest  of  circulation. 

17p  to  the  third  month  the  intestine  extends  a  little  way  into  the 
umbilical  cord ;  at  that  time  it  becomes  retracted  into  the  abdomen. 
The  arteries  are  external  to  the  vein  which  lies  between  them 
(Fig.  84).  They  have  no  branches,  and  have  the  peculiarity  that 
they  increase  in  diameter  from  the  fcetus  towards  the  placenta, 
so  that  the  current  of  blood  becomes  slower  in  approaching  the 
placenta.  The  vessels  are  peculiar  in  their  structure,  since  they 
consist  almost  entirely  of  muscle  tissue.  There  is  a  rudimentary 
internal  coat,  but  practically  no  tunica  adventitia.  No  elastic 
tissue    is    present,  and    the    muscle    fibres   are    arranged   mainly 

longitudinally.  The  trans- 
verse diameter  of  the  arteries 
is  about  3  to  5  cm.,  while  that 
of  the  veins  is  from  5'5  to 
7*5  cm.  Both  the  arteries 
and  the  veins  contain  semi- 
lunar or  circular  valves,  valves 
of  Hoboken,  formed  by  fold- 
ings of  the  vessel  walls,  which 
are  more  numerous  in  the 
former  than  in  the  latter. 

There  are  no  capillaries  in 
the  cord  after  an  early  stage 
of  pregnancy,  except  a  few 
which  extend  a  short  distance  into  it  from  the  skin  of  the  foetus. 
But  vasa  propria  of  the  cord  have  been  described  as  existing  at  a 
very  early  stage  of  pregnancy,  derived  from  the  umbilical  arteries. 
There  are  no  lymphatics,  but  nerves  have  been  described  mainly 
towards  the  fcetal  end  of  the  cord. 

The  pedicle  of  the  umbilical  vesicle  becomes  embedded  in  the  funis, 
which  folds  over  it  from  each  side,  at  an  early  stage  of  develop- 
ment. In  a  microscopic  section  of  the  funis  the  allantois  is  visible 
only  near  the  fcetal  attachment,  as  a  small  duct  lined  with  cuboidal 
or  flattened  epitheHum.  The  section  of  the  pedicle  of  the  umbihcal 
vesicle  may  be  seen  at  any  part,  but  more  often  toward  the  placental 
attachment,  and  presents  a  similar  appearance. 

Spiral  Ticist  of  the  Cord. — In  early  pregnancy,  when  the  cord  is 
short,  the  arteries  run  parallel,  or  nearly  so  (Fig.  82,  p.  110),  but  at 
the  end  of  pregnancy  there  is  a  spiral  twist,  which,  in  about  nine 


Fig.  8J. — Section  of  umbilical  cord, 
arteries ;  r,  vein  ;  all,  remains 
allantois. 


of 


The  Chorion,  Placenta,  and   Umbilical  Cord.     113 

cases  out  of  ten,  is  from  right  to  left,  over  the  anterior  surface 
when  regarded  from  the  umbilical  end.  This  implies  that  the 
fcetus  must  have  made  a  corresponding  number  of  revolutions 
upon  its  axis.  The  cause  of  the  twist  has  not  been  satisfactorily 
explained.      It  is  most  probably  due  to  the  fact  that  the  vessels 


W7ft 


cl 


u.u. 


^ 


-M-IA 


a/nt 


^iC.C. 


U/lh 


oA 


Fig.  85. — Diagrams  illustrating  the  formation  of  the  umbilical  cord.i 
am.  amnion;  ep.  epiblast :  «.r.  umbilical  vesicle:  sf.  ventral  and  abdo- 
minal stalk;  ch.  chorion:  «?.  allantois.  The  gradual  enclosing  of  the 
heart  rudiment,  the  shifting  of  the  ventral  stalk  on  to  the  abdominal 
aspect  of  the  embryo,  the  coalescence  of  the  stalk  of  the  umbilical 
vesicle  with  the  abdominal  stalk  containing  the  chorionic  vessels,  the 
ultimate  position  of  the  remains  of  the  umbilical  vesicle  on  the  surface 
of  the  placenta  under  the  amnion,  and  the  derivation  of  the  epithelial 
covering  of  the  cord  from  the  epiblast  are  all  shown. 


grow  faster  than  the  cord,  with  the  result  that  the  latter 
becomes  disposed  in  a  spiral  fashion.  It  has  been  ascribed  to  the 
pressure  in  the  umbilical  vessels,  to  the  movements  of  the  fa?tus, 
to  the  action  of  its  heart,  or  the  pressure  in  its  vessels.     If  it  be 

Modified  from  Grosser,  Anatomic  und  Entwicklun'^^geschichte  der  Eiliiiute  u.  dor 
Placenta,  1909. 

M.  ft 


114  The  Practice  of  Midwifery. 

assumed  that  the  left  leg  is  congenitally  stronger  than  the  right, 
corresponding  with  the  right  arm,  and  that  it  is  used  more  strongly 
by  the  foetus  in  kicking,  the  usual  direction  of  the  rotations,  and  of 
the  consequent  spiral  in  the  cord,  will  be  accounted  for.  Nodosities 
are  often  seen  upon  the  cord,  due  to  torsion  anomalies  of  the  vessels, 
varicose  nodes,  or  heaping  up  of  Wharton's  jelly. 


Chapter  V. 
DEVELOPMENT   OF  THE   FCETUS. 

No  general  description  of  the  development  of  the  foetus  will  here 
be  given,  since  this  subject  belongs  rather  to  works  on  embryology. 
But  since  it  is  often  of  practical  importance  to  be  able  to  judge  of 
the  age  of  an  ovum  or  foetus  expelled  prematurely,  the  following 
particulars  are  given  as  to  the  characters  to  be  recognised  at  each 
month.  It  is  to  be  remembered,  however,  that  the  measurements 
of  weight  and  length  are  only  to  be  taken  as  approximate  guides, 
since  great  varieties  occur  according  to  the  rapidity  and  vigour  of 
development  in  different  cases.  In  estimating  the  age  of  the  foetus 
towards  the  latter  months  of  pregnancy,  the  length  of  the  foetus  is 
of  greater  value  than  the  weight,  not  being  subject  to  such  wide 
variations.  The  months  of  pregnancy  are  to  be  understood  as 
meaning  calendar  months,  here  and  elsewhere  in  this  work,  unless 
it  is  otherwise  stated. 

First  Month. — An  ovum  has  been  described,  at  the  beginning  of 
the  second  week,  whose  diameter  was  about  ^  inch,  and  one  whose 
age  was  estimated  at  about  12  days  and  whose  diameter  was  about 
f  inch ;  the  length  of  the  embryo  was  one  line  (Fig.  87,  p.  117). 
At  the  end  of  the  third  week  the  diameter  of  the  ovum  is  about 
f  inch,  the  length  of  the  embryo  two  lines.  The  amnion  is 
formed,  the  embryo  is  nourished  by  the  umbilical  vesicle,  it  is  very 
much  bent  upon  itself  so  that  the  head  and  the  tail  almost  overlap, 
and  the  enlargement  of  its  cephalic  extremity  is  marked.  About  this 
time  the  vessels  are  reaching  the  chorion  by  the  umbilical  pedicle. 
At  the  end  of  the  fourth  week,  the  greatest  diameter  of  the  ovum  is 
about  I  inch  (2  cm.)  its  weight  about  40  grains  (2*59  gm.).  The 
length  of  the  embryo  is  about  ^inch  (1  cm.),  measured  in  a  straight 
line  from  the  head  to  the  most  prominent  part  of  the  caudal  curve. 
The  eyes  and  ears,  the  visceral  arches,  and  the  mesodermic  segments 
are  distinguishable.  Four  bud-like  processes  mark  the  commence- 
ment of  the  limbs.  The  umbilical  vesicle  is  manifest,  but  smaller 
than  the  embryo,  and  the  abdominal  stalk  and  vitelline  stalk  are 
close  to  one  another.  The  amnion  closely  invests  the  embryo,  and 
is  separated  by  an  interval  from  the  chorion. 

Second  Month. — At  the  end  of  the  second  month,  the  ovum  is 

8—3 


ii6 


The  Practice  of  Midwifery. 


about  2|  inches  (6*5  cm.)  in  its  greatest  diameter,  the  embryo  1^  inch 
(3  cm.)  long,  measured  as  before  in  a  straight  hne,  and  its  weight 
about  240  grains  (15*4  gm.).  The  umbilical  vesicle  is  very  small, 
and  hangs  only  by  a  withered  thread.     The  increased  proliferation 


Fig.  86. — Early  human  ovum  in  situ,  showing  the.  short  thick  umbilical  cord, 
the  umbilical  vesicle,  the  chorion,  amnion,  decidua  reflexa,  and  decidua 
vera.i 


of  villi  at  the  site  of  the  future  placenta  is  manifest  (see  Fig.  72, 
p.  96).  The  funis  is  straight,  about  10  mm.  in  length  (see  Fig.  82, 
p.  110),  the  amnion  is  considerably  distended,  and  reaches  the 
chorion   or  nearly  so.      The    umbilical  ring  is  closing,   but  still 

1  Univ.  Coll.  Hosp.  Med.  School  Mus.,  No.  4177a. 


Development  of  the   Foetus.  1 1 7 

contains  a  loop  of  intestine.  The  limbs  project  beyond  the  body, 
but  the  legs  are  still  smaller  than  the  arms.  Points  of  ossification 
have  appeared  in  the  lower  jaw  and  clavicle.  The  mouth  and  nose 
are  manifest.  The  nose  is  broad  and  flat,  and  the  nostrils  look 
forwards.  The  Wolffian  bodies  have  become  atrophied,  and  the 
kidneys  have  appeared.  The  head  is  nearly  as  large  as  the  body  of 
the  embryo.     The  back  is  straighter  and  the  curvature  less  marked. 


i) 


t'->:,,^ 


Fig.  87. — Series  of  embryos,  from  His,  of  the  first  and  second  months  of 
pregnancy,  measuring  respectively  2'1,  4'2,  7-5,  13'7,  15'5,  and  23  mm.  in 
length. 

the  tubercle  of  the  tail  is   still  present,  but  the  embryo  is  now 
definitely  human  and  may  be  termed  the  f^tus  (Fig.  87). 

Third  Month. — At  the  end  of  the  third  month  the  ovum  is  about 
4  inches  long  (10  cm.),  the  amnion  fills  the  whole  chorionic  vesicle, 
the  placenta  is  formed,  and  the  rest  of  the  chorion  has  to  a 
considerable  extent  lost  its  villosity.  The  cord  has  now  become 
long  relatively  to  the  fcjetus,  and  already  shows  its  spiral  twist. 
Its  point  of  insertion  is  much  nearer  to  the  breech  than 
the  head.  The  foetus  is  about  3^  inches  (8  cm.)  long  from  head 
to  feet,  and  weighs  about  3  ounces  (84-9  gm.).  The  head  is 
separated  from   the   body   by    the    neck,  and    the   oral  from   the 


ii8  The  Practice  of   Midwifery. 

nasal  cavity  by  the  palate ;  the  mouth  is  also  closed  by  lips. 
The  sexual  organs  have  appeared,  but  penis  and  clitoris  are 
scarcely  distinguishable.  The  vitelline  coil  is  withdrawn  from  the 
umbilical  ring  into  the  abdomen.  The  limbs  are  developed, 
including  the  fingers  and  toes,  and  a  first  appearance  of  formation 
of  nails  can  be  detected.  Points  of  ossification  have  appeared  in 
most  of  the  bones. 

Fourth  Month. — At  the  end  of  the  fourth  month  the  foetus  is  on 
an  average  about  5|  inches  long  (13  cm.),  and  weighs  about  7 J 
ounces  (204  gm.).  The  sex  can  now  be  distinctly  recognised.  The 
bones  of  the  skull  have  partly  ossified,  but  still  have  very  wide 
fontanelles  and  sutures.  The  skin  is  firm  and  rose-coloured.  The 
head  occupies  about  one-fourth  of  the  whole  body  length,  and 
short  colourless  hair  is  beginning  to  appear  on  it.  There  is  a  slight 
commencement  of  formation  of  down  on  the  skin.  The  legs  and 
arms  are  of  the  same  length,  and  movements  of  the  limbs  have 
commenced.  These  may,  however,  be  detected  in  a  freshly-expelled 
embryo  even  before  the  end  of  the  third  month.  The  umbilicus  is 
close  above  the  pubes. 

Fifth  ]\[onth. — The  foetus  is  on  an  average  9  inches  long 
(22"5  cm.),  and  weighs  about  1  pound  (450  gm.).  The  hair 
upon  the  head  is  better  developed,  and  lanugo  or  down  has  appeared 
over  the  whole  body.  The  skin  begins  to  be  covered  with  the 
"  vernix  caseosa,"  a  white  greasy  substance  made  up  of  the 
secretion  of  the  cutaneous  glands  mixed  with  epithelium.  The 
liquor  amnii  still  exceeds  the  fcetus  in  bulk.  A  foetus  born  at  this 
time  may  make  vigorous  movements  at  birth,  and  continue  them 
for  some  hours. 

Sixth  Month. — The  foetus  is  about  12  inches  long  (30  cm.),  and 
weighs  from  2  to  2|  pounds  (900 — 1,100  gm.).  The  eyebrows  and 
eyelashes  are  beginning  to  form.  Deposit  of  fat  in  the  subcu- 
taneous cellular  tissue  is  beginning,  but  only  in  a  small  degree,  so 
that  the  skin  still  has  a  wrinkled  appearance.  There  is  yellowish 
material  in  the  small  intestine,  and  there  may  be  a  commencing 
appearance  of  the  darker  "meconium  "  in  the  large  intestine.  The 
hair  on  the  head  is  longer  and  less  like  down. 

Seventh  Month.- — The  average  length  is  15  inches  (37*5  cm.),  and 
weight  from  3  to  4  pounds  (or  about  Ih  kilo.).  The  eyelids  are 
now  open,  and,  in  a  boy,  one  testicle  is  generally  descending  into 
the  scrotum.  The  nails  are  thicker,  but  do  not  reach  the  tips  of 
the  fingers.  The  lanugo  is  beginning  to  disappear  from  the  face. 
It  is  generally  considered  that  the  foetus  does  not  become  "  viable," 
or  capable  of  surviving,  till  the  end  of  the  twenty-eighth  week,  or 


Development  of  the   Foetus.  119 

the  seventh  lunar  month.  Children  born  earlier  perish  after  a  few 
hours  or  days.  There  is  a  considerable  number  of  recorded  cases, 
however,  in  which  premature  children  have  survived,  whose  age 
at  birth  was  reckoned  as  less  than  this  both  from  the  dates  given 
by  the  parents  and  the  appearance  of  the  children  themselves.^ 

Eighth  Month. — The  average  length  is  16|  or  17  inches  (40 — 
42  cm,),  the  weight  4^  or  5  pounds  (2 — 2J  kilo.).  Owing  to  greater 
deposit  of  fat,  the  wrinkled  appearance  of  the  skin  has  nearly  dis- 
appeared, and  it  is  now  flesh-coloured.  Lanugo  still  covers  the 
body,  but  is  beginning  to  be  thrown  off.  The  scrotum  contains  at 
least  one  testicle,  usually  the  left.  Children  born  at  this  time  are 
much  less  active  and  more  somnolent  than  those  which  have  reached 
full  term.  The  mortality  among  them  is  greater,  and  they  readily 
perish  if  not  well  cared  for,  although  they  survive  as  a  rule  if 
carefully  tended. 

The  Foetus  at  Full  Term.— The  average  length  is  21  inches 
(50  cm.),  and  weight  7  pounds  (3 — 3 J  kilo.).  The  skin  is  whiter, 
not  so  red  as  in  premature  children,  the  finger-nails  project 
beyond  the  tips  of  the  fingers,  the  toe-nails  reach  the  ends  of 
the  toes.  The  hair  on  the  head  is  from  1  to  2  inches  long,  and 
generally  dark ;  the  lanugo  has  been  thrown  off  for  the  most  part, 
but  is  still  found  on  the  shoulders.  Both  testicles  can  be  felt  in  the 
scrotum,  and  in  the  female  the  labia  majora  are  in  contact,  and 
cover  in  the  labia  minora. 

The  umbilicus  is  nearer  the  centre  of  the  body  than  in  earlier 
months,  being  only  about  three-quarters  of  an  inch  below  the  exact 
centre.  The  child,  unless  asphyxiated,  cries  vigorously  with  a  loud 
voice  immediately  after  birth,  and  actively  moves  its  limbs. 
Within  a  few  hours  it  passes  urine  and  meconium.  The  latter 
consists  of  intestinal  mucus  mixed  with  epithelium,  lanugo,  and 
bile,  which  gives  it  a  dark  brownish-green,  or  nearly  black,  colour. 

With  regard  to  the  weight  of  the  foetus,  variations  between  6 
and  8  pounds  are  very  common.  Children  are  sometimes  born  at 
full  term,  and  survive,  which  weigh  less  than  5  pounds.  As  a 
rule,  however,  a  child  which  weighs  under  5  pounds  at  full  term 
has  little  chance  of  living.  If  premature,  its  chances  are  much 
l^etter.  Weights  above  10  pounds  (4,530  gm.)  are  uncommon,  and 
those  above  12  (5,400  gm.)  very  rare.  There  is,  however,  a  con- 
siderable number  of  recorded  cases  of  children  weighing  from  12 
up  to  nearly  18  pounds  (8,150  gm.).  Such  children  have  generally 
been  still-born  ;  but  Sir  Richard  Croft  is  said  by  Dr.  Rigby  to  have 

I  Sec  a  paper  by  Ahlfeld,  Arch.  f.  Gymik.,  VIII.,  s.  I'Jt. 


I20  The  Practice  of   Midwifery. 

delivered  a  living  child  weighing  15  pounds,  and  Dr.  Waller  reports 
a  living  child  delivered  by  forceps,  and  weighing  18  pounds  15  ounces 
(8,570  gm.).^  The  length  of  the  foetus  varies  much  less  widely 
than  the  weight,  but  may  reach  as  much  as  24|  inches  (60 — 
61  cm.),  the  average  being  19^ — 23 J  inches  (48 — 58  cm.).  Dead 
children,  owing  to  the  loss  of  tone  in  the  muscles,  usually  measure 
1"5 — 2  cm.  longer  than  living  children  of  the  same  age. 

The  weight  of  the  ftetus  is  affected  by  various  circumstances. 
The  stature  and  bulk  of  the  father  and  mother  naturally  have  an 
influence.  Males  are,  on  the  average,  heavier  than  females,  the 
proportion  being  about  12  to  11.  Children  generally  increase  in 
weight  in  successive  pregnancies  if  they  do  not  occur  too  frequently. 
This  may  depend,  in  a  measure,  upon  the  effect  of  repeated  par- 
turition, but  probably  in  greater  degree  upon  the  age  of  the  mother, 
for  it  has  been  found  that  the  heaviest  children  are  born  between 
the  ages  of  25  and  35.  Hence,  if  there  is  disproportion  between 
the  fcetus  and  the  bony  pelvis,  later  labours  are  often  more  difficult 
than  the  earlier  ones.  Beyond  the  age  of  35,  or  after  the  ninth 
pregnane}^  the  weight  of  the  children  tends  again  to  diminish. 

Legitimate  children  are  heavier  than  illegitimate  as  a  rule,  and 
it  has  been  shown  that  if  the  mother  is  able  to  rest  during  the 
latter  weeks  of  her  pregnancy,  the  child  will'  be  heavier  than  if 
she  has  to  work  hard  up  to  the  date  of  her  confinement. 

Excessive  size  of  the  fcetus  may  be  due  to  post-maturity  ;  for 
very  large  children,  with  unusually  ossified  bones,  have  been  born 
when  labour  has  not  occurred  for  several  weeks,  or  even  over  a 
month,  beyond  the  expected  date. 

In  14  to  15  per  cent,  of  all  children  weighing  over  8f  pounds 
(4,000  gm.)  the  pregnancy  has  lasted  more  than  300  days.  For 
two  or  three  days  after  birth,  and  before  the  secretion  of  milk  is 
fully  established,  the  child  loses  weight.  The  number  of  boys  born 
exceeds  that  of  girls  in  the  proportion  of  about  106  to  100.  In 
elderly  primiparse  the  disproportion  is  greater.  Between  the  ages 
of  30  and  40  it  is  about  125  to  100 ;  between  the  ages  of  40  and  50, 
about  135  to  100.^ 

According  to  Haase,^  the  following  rule  gives  approximately  the 
length  of  the  embryo,  measured  from  vertex  to  sole  of  foot,  in 
centimetres  at  the  end  of  each  of  the  ten  lunar  months  of  gestation. 
For  the  first  five  months  square  the  number  of  the  month  to  which 
the  pregnancy  has  advanced.     For  the  second  five  months  multiply 

1  Trans.  Obst.  Soc.  London,  1860,  Vol.  L,  p.  309. 

2  Ahlfeld.,  Arch.  f.  Gyn.,  1871,  IJ.  353—372. 
8  Charit^-Annalen,  II.  686. 


Development  of  the   Foetus. 


121 


the  number  of    the    month  by  5.      Hence  we   get  the  following 
table : — 


At  the  end  of  the  first  month  - 
second  month 


Length  of  foetus. 

1x1=    1  centimetre. 
2X2=4 


third  month 

-3x3=9 

fourth  month 

-     4  X  4  =  16 

fifth  month 

-     5  X  5  =  25 

sixth  month 

-     6  X  5  =  30 

seventh  month 

-     7  X  5  =  35 

eighth  month 

-     8  X  5  =  40 

ninth  month 

-     9  X  5  =  45 

tenth  month 

-  10  X  5  =  50 

Circulation  of  the  Foetus.— The  umbilical  vein,  which  brings 
the  aerated  blood  from  the  placenta,  divides  at  the  transverse 
fissure  of  the  liver  into  two  branches.  The  larger  of  these  unites 
with  the  portal  vein,  and  supplies  the  liver  ;  the  lesser,  the  ductus 
venosus,  passes  directly  to  the  inferior  vena  cava.  Thus  the  greater 
part  of  the  aerated  blood  has  to  pass  through  the  liver  before 
reaching  the  general  circulation,  and  this  proportion  becomes 
greater  towards  the  latter  part  of  pregnancy.  The  right  auricle 
receives  from  the  inferior  vena  cava  a  mixture  of  venous  blood  from 
the  lower  parts  of  the  body  with  aerated  blood  from  the  placenta, 
either  direct  or  after  passing  through  the  liver. 

In  the  earlier  months  of  foetal  life,  the  blood  current  of  the 
inferior  vena  cava  is  directed  by  the  Eustachian  valve  across  the 
right  auricle,  through  the  foramen  ovale  into  the  left  auricle,  and 
thence  to  the  left  ventricle.  The  venous  blood  returning  from  the 
upper  part  of  the  body  by  the  superior  vena  cava,  passes  in  front 
of  the  Eustachian  valve,  through  the  right  auricle  into  the  right 
ventricle.  Thence  it  is  driven  into  the  pulmonary  artery,  whence 
only  a  small  proportion  passes  to  the  lungs,  while  the  major  part 
passes  through  the  ductus  arteriosus  into  the  aorta  beyond  the 
point  of  origin  of  the  left  subclavian  artery,  and  so  is  distributed 
to  the  lower  part  of  the  body. 

Thus  in  the  earlier  part  of  foetal  life,  while  the  Eustachian  valve 
almost  entirely  prevents  a  mixing  of  the  currents  in  the  right 
auricle,  the  head,  neck,  upper  extremities,  and  liver  are  supj)lied 
with  almost  pure  aerated  blood,  the  lower  part  of  the  body  only 
with  venous  blood  which  has  already  passed  through  the  other  part 
of  the  circulation.     Thus  is  explained  the  disproportionately  rapid 


O  A 


5lfH\20/ 


\i  tj 


Fig.  88. — Diagram  of  the  foetal  circulation.  1,  the  umbilical  cord,  consisting 
of  the  iimbilical  vein  and  two  umbilical  arteries,  proceeding  from  the 
placenta  (2)  ;  3,  the  umbilical  vein  dividing  into  three  branches — two 
(4,  4)  to  be  distributed  to  the  liver,  and  one  (5)  the  ductus  venosus,  which 
enters  the  inferior  vena  cava  (6)  ;  7,  the  portal  vein,  returning  the  blood 
from  the  intestines,  and  uniting  with  the  right  hepatic  branch  ;  8,  the 
right  auricle — the  course  of  the  blood  is  denoted  by  the  arrow  proceeding 
from  8  to  9  ;  9,  the  left  auricle  ;  10,  the  left  ventricle — the  blood 
following  the  arrow  to  the  arch  of  the  aorta  (11),  to  be  distributed 
through  the  branches  given  off  by  the  arch  to  the  head  and  upper 
extremities  ;  the  arrows  (12)  represent  the  return  of  the  blood  from  the 
head  and  upper  extremities  through  the  jugular  and  subclavian  veins,  to 
the  superior  vena  cava  (14),  to  the  right  auricle  (8),  and  in  the  course  of 
the  arrow  through  the  right  ventricle  (15)  to  the  pulmonary  artery  (16) ; 
17,  the  ductus  arteriosus,  which  appears  to  be  a  proper  continuation  of  the 
pulmonary  artery — the  offsets  at  each  side  are  the  right  and  left 
pulmonary  arteries  cut  off  ;  the  ductus  arteriosus  joins  the  descending 
aorta  (18,  18),  which  divides  into  the  common  iliacs,  and  these  into  the 
internal  iliacs,  which  become  the  umbilical  arteries  (19),  and  return  the 
blood  along  the  umbilical  cord  to  the  placenta,  and  the  external  iliacs  (20), 
which  are  continued  into  the  lower  extremities.  The  arrows  at  the 
termination  of  these  vessels  mark  the  return  of  the  venous  blood  by  the 
veins  to  the  inferior  cava.    (After  Carpenter.) 


Development  of  the   Foetus.  123 

development  of  the  head  and  upper  part  of  the  body  and  of  the 
liver,  more  especially  in  the  early  part  of  foetal  life. 

A  change,  however,  takes  place  by  about  the  middle  of  pregnancy. 
The  Eustachian  valve  becomes  smaller,  and  the  valve  of  the  foramen 
ovale  becomes  more  developed,  so  that  a  portion  of  the  aerated 
blood  entering  from  the  inferior  vena  cava  is  retained  in  the  right 
auricle,  and  reaches  the  descending  aorta  by  way  of  the  ductus 
arteriosus.  Hence,  in  the  latter  half  of  pregnancy,  the  lower  part 
of  the  body  is  supplied,  no  longer  with  venous,  but  with  mixed 
blood,  while  the  head  and  upper  limbs  are  still  supplied  with  com- 
paratively pure  aerated  blood.  This  explains  the  fact  that  a 
relatively  more  rapid  growth  of  the  lower  part  of  the  body  takes 
place  in  the  latter  half  of  pregnancy  than  in  the  former. 

Changes  in  the  Foetal  Circulation  at  Birth. — As  soon  as  the 
child  is  born  an  immediate  change  takes  place  in  the  circulation. 
As  soon  as  the  first  respiratory  movements  take  j)lace,  and  air 
enters  the  lungs,  the  pulmonary  arteries  immediately  dilate,  and  a 
greatly  increased  stream  of  blood  passes  through  the  lungs,  and, 
returning  to  the  left  auricle,  raises  the  pressure  in  it.  At  the  same 
time  the  placenta  is  detached,  the  circulation  through  it  soon  ceases, 
and,  by  the  cessation  of  the  current  from  the  umbilical  vein,  the 
pressure  in  the  right  auricle  is  lowered.  The  two  causes  combined 
render  the  pressure  in  the  left  auricle  greater  than  that  in  the 
right,  the  valve  of  the  foramen  ovale  is  thereby  closed,  and  blood  no 
longer  passes  between  the  auricles.  Moreover,  as  soon  as  the  main 
stream  of  blood  propelled  by  the  right  ventricle  begins  to  pass 
through  the  lungs,  the  pressure  in  the  ductus  arteriosus  is  lowered. 
The  ductus  is  then  gradually  diminished  by  the  contractility  of  its 
own  walls,  and,  at  the  end  of  a  few  days,  is  practically  closed, 
though  not  absolutely  obliterated  for  some  time  longer.  The  walls 
come  into  contact,  and  the  lumen  is  obliterated  finally  by  hyper- 
trophy of  the  internal  coat  and  the  formation  of  new  connective 
tissue  without  the  formation  of  any  thrombus.  A  small  cavity 
remains  at  the  aortic  end  of  the  duct  for  a  considerable  time,  the 
pressure  in  the  aorta  being  now  greater  than  that  in  the  pulmonary 
artery. 

The  edges  of  the  valve  of  the  foramen  ovale  also  generally  become 
adherent  and  unite  after  a  few  days.  The  opening  may  remain 
ununited,  however,  for  some  little  time  without  any  blood  passing 
through  it.  A  patent  condition  of  the  opening  after  birth  is  one  of 
the  causes  of  cyanosis  in  infants. 

The  blood  pressure  in  the  descending  aorta  becoming  diminished 


124  The   Practice  of   Midwifery. 

when  it  no  longer  receives  blood  through  the  ductus  arteriosus,  the 
umbilical  arteries  also  contract  to  some  extent,  thrombi  are  formed 
in  them,  and  they  become  obliterated.  The  umbilical  vein  is  also 
closed  either  by  simple  contraction  or  by  thrombus. 

It  is  remarkable  with  how  little  disturbance  the  important  changes 
which  transform  the  circulation  of  the  fcetus  in  utero  to  that 
required  for  its  extra-uterine  existence  are  carried  out. 

Physiology  of  the  Fcetus. — Our  knowledge  of  foetal  physiology 
is  of  the  scantiest  description,  but  there  are  certain  facts  which 
have  been  ascertained,  and  which  throw  some  light  upon  the  many 
interesting  problems  involved.  A  most  interesting  feature  in  con- 
nection with  the  foetal  heart  is  its  power  of  continuing  to  beat  for 
long  periods  of  time  after  the  birth  of  the  foetus  and  independently 
of  the  central  nervous  system.  Thus  Neugebauer  has  recorded  a  case 
in  which  the  heart  continued  to  beat  in  the  trunk  of  a  mutilated 
foetus  for  more  than  three  hours.  Another  striking  feature  is  the 
power  of  the  foetal  heart  to  continue  to  beat  without  any  attempts 
at  respiration  being  made  by  the  foetus.  Ballantyne  records  a  case, 
for  example,  where  the  heart  beat  for  five  hours  after  birth  in  such 
conditions. 

The  blood  of  the  foetus  is  relatively  rich  in  red  corpuscles  and 
haemoglobin,  and  also  exhibits  some  degree  of  leucocytosis.  It  con- 
tains a  certain  number  of  nucleated  red  cells,  and  it  is  said  that  the 
foetal  oxyhEEmoglobin  is  more  difficult  to  reduce  than  that  of  the 
mother.^ 

Beyond  the  fact  that  for  its  respiration  the  foetus  is  dependent 
upon  the  integrity  of  the  placental  circulation,  very  little  is  known 
of  the  manner  in  which  this  function  is  carried  out,  and  we  are 
entirely  ignorant  of  the  way  in  which  the  gaseous  interchanges  take 
place  between'the  maternal  and  foetal  blood. 

The  fact  already  mentioned  that  the  living  foetus  has  a  slightly 
higher  temperature  in  utero  than  its  mother,  and  the  further  fact 
that  various  products  of  tissue  change  have  been  demonstrated  in 
its  tissues,  seems  to  prove  that  a  certain  degree  of  metabolism  takes 
place  in  its  body,  and  Ballantyne  has  made  the  interesting  sugges- 
tion that  its  metabolism  may  display  some  similarity  to  that  of  a 
hibernating  animal.^ 

Chemical  analyses  of  the  tissues  of  the  foetus  and  its  placenta 
show  that  the  former  stores  up  in  its  body  during  intra-uterine  life 

1  G-.  Zanier,  Arch.  Ital.  de  Biol.,  1896,  XXV.,  p.  .58. 

2  J.  W.  Ballantyne,  Manual  of  Ante-natal  Pathology,  1902,  to  which  the  student 
should  refer  for  further  information  on  foetal  physiology. 


Development  of  the   Foetus.  125 

a  considerable  quantity  of  iron  and  fat,  the  latter,  according  to 
Thiemich,^  not  derived  from  the  fat  in  the  mother's  food.  The 
placenta  (see  p.  108)  is  undoubtedly  the  chief  source  of  nutrition  to 
the  foetus,  and  it  seems  probable  that  not  only  has  it  the  power 
of  storing  up  certain  substances,  but  that  it  possesses  also  the 
property  of  initiating  chemical  changes  in  the  substances  passing 
through  it,  and  further  exerting  a  selective  action  on  those  it 
allows  to  pass  to  the  foetus,  the  so-called  barrier  action  of  the 
placenta.  In  the  earliest  weeks  of  development  the  human  ovum 
is  nourished  by  the  cells  of  the  trophoblast,  and  no  doubt  to  a 
small  extent  by  absorption  from  the  umbilical  vesicle ;  the  latter  is, 
however,  an  unimportant  structure  in  man,  and,  as  we  have  seen, 
the  chorionic  circulation  becomes  established  at  a  very  early  age 
(see  p.  91).  That  the  foetus  swallows  some  of  the  liquor  amnii 
is  certain,  and  although  the  amount  of  nutrition  it  may  derive 
from  this  source  is  very  small,  yet  it  may  well  obtain  its  supj)ly  of 
water  in  this  manner. 

The  function  of  excretion,  like  that  of  nutrition  and  respiration, 
is  mainly  carried  out  by  means  of  the  placenta,  but  a  certain 
amount  of  waste  material  is  contained  in  the  meconium  and  the 
foetal  urine. 

Of  the  functions  of  the  other  organs  of  the  foetus  our  knowledge 
is  exceedingly  fragmentary,  but  it  would  seem  that  the  liver  has  an 
important  function  in  foetal  life,  since  its  relative  weight  is  so  much 
greater  than  after  birth,  and  it  receives  the  purest  blood  from  the 
placenta. 

Sugar  is  found  in  the  foetus  in  larger  quantities  than  after  birth, 
and  the  glycogenic  function  of  the  liver  is  doubtless  an  important 
one  from  the  time  of  its  development.  The  sugar  is  found,  how- 
ever, even  earlier  than  this ;  and,  at  this  stage,  the  glycogenic 
function  appears  to  be  fulfilled  by  other  tissues,  especially  by  the 
placenta,  while  glycogen  can  be  found  in  most  young  foetal  tissues, 
viz.,  muscle  and  heart. 

About  the  third  month  the  liver  cells  begin  to  assume  their 
characteristic  features,  and  bile  to  be  secreted.  Bile  has  already 
been  mentioned  as  a  constituent  of  the  meconium,  to  which  it  gives 
its  characteristic  green  colour.  The  gall-bladder  is  also  generally 
filled  at  the  time  of  birth. 

The  brain  cells  of  the  foetus  are  in  a  rudimentary  condition  up  to 
birth.  There  is,  however,  a  discharge  of  energy  from  time  to  time 
causing  the  movements  of  the  limbs.  Reflex  movements  are  also 
provoked  by  stimulus  applied  to  the  surface  of  the  body.     They  are 

1  Zentralbl.  f.  Physiol.,  18i)'J,  XII. 


126  The   Practice  of   Midwifery. 

easily  excited  by  pressure  through  the  walls  of  the  abdomen  and 
uterus,  and  may  also  be  called  out  by  uterine  contractions,  when  the 
foetus  is  so  placed  that  contraction  causes  pressure  on  any  special 
parts.  It  must,  however,  be  remembered  that  fcetal  movements 
may  be  met  with  independently  of  the  cerebrum  and  medulla,  since 
they  may  occur  in  anencephalic  and  acephalic  foetuses  and  at  times 
after  craniotomy. 


Chapter  VL 
THE  ANATOMY  OF  THE  FCETAL  HEAD. 

The  head  of  the  foetus  is  the  part  which,  in  almost  all  cases, 
passes  with  greatest  difficulty  through  the  pelvis  ;  and  the  behaviour 
of  the  head  during  its  passage  must  of  course  depend  upon  the 
mutual  relations  between  the  head  and  the  j)elvic  cavity.  In  order, 
therefore,  to  understand  the  mechanism  of  labour  it  is  as  necessary 
to  study  the  anatomy  of  the  foetal  head  as  that  of  the  pelvis. 

The  head  of  the  fully-developed  foetus  forms  an  irregular  ovoid, 
whose  compressibility  varies  greatly  according  to  the  diameter  in 
which  the  compressing  force  is  applied.  In  reference  to  midwifery, 
the  head  may  be  regarded  as  made  up  of  two  parts,  the  incom- 
pressible base,  including  the  bones  of  the  face,  and  the  compressible 
vault  or  calvarium.  The  bones  of  the  base  of  the  skull  and  face 
are  early  developed,  so  that  by  the  time  of  birth  they  are  practically 
unyielding  in  their  texture,  and  for  the  most  part  immovably  united 
to  each  other.  In  consequence  of  this  the  various  imj)ortant  ganglia 
and  organs  of  special  sensation  at  the  base  of  the  brain  are  protected 
from  injury,  as  the  head  is  compressed  during  labour.  The  bones 
which  make  up  the  calvarium,  on  the  contrary,  instead  of  being 
ossified  together  as  in  later  life,  are  connected  only  by  membrane, 
while  the  bones  themselves,  in  the  great  majority  of  cases,  are  soft 
and  semi-cartilaginous,  esj)ecially  towards  the  edges.  The  individual 
bones  are  thus  movable,  and  may  be  made  to  overlap  each  other  to 
a  considerable  extent.  The  shape  of  the  head  can  be  altered  by 
moulding,  according  to  the  exigencies  of  the  case,  not  only  by  this 
relative  movement  and  overlai^ping  of  the  bones,  but  still  more  by 
actual  bending  of  the  bones  themselves,  more  especially  of  the 
parietal  bones,  which  are  the  softest.  The  effect  of  the  pressure  on 
the  head  during  labour  is  to  diminish  the  capacity  of  the  whole 
cranium.  This  is  proved  by  the  rapid  increase  of  the  average 
diameters  of  the  foetal  head  which  takes  place  during  the  first  two 
or  three  days  after  birth,  at  a  time  when  the  weight  of  the  whole 
child  is  actually  diminishing.  It  is  brought  about  mainly  by 
cerebro-spinal  fluid  being  squeezed  out  of  the  head  into  the  spinal 
canal,  but,  to  some  extent  also,  by  the  blood  being  similarly 
squeezed  out  into  the  veins  of  other  parts.     The  brain  substance 


128 


The  Practice  of   Midwifery. 


of  the  hemispheres,  bemg  but  Httle  developed  at  the  tmie  of  birth, 
is  able  to  undergo  considerable  compression  and  moulding  without 
permanent  injury.  As  the  head  becomes  compressed,  the  parietal 
bones  invariably  overlap,  or  tend  to  overlap,  both  the  frontal  and 
occipital  bones.  It  will  be  seen  hereafter  that  a  knowledge  of  this 
fact  is  of  very  practical  importance  in  facilitating  the  diagnosis  of 
the  position  of  the  head  in  vertex  presentations.  The  parietal  bone 
which  is  anterior  in  the  pelvis  generally  overlaps  the  posterior  in 
vertex  presentations,  because  it  receives  less  support  from  the 
soft  parts. 

The  face,  as  compared  with  that  of  the  adult,  is  very  small  in 
proportion  to  the  cranium.     The  lower  jaw  especially  is  widely 

different  from  the  adult  maxilla, 
the  ramus  being  short  and 
oblique,  so  that  the  toothless 
maxillfie  come  into  close  contact, 
and  both  chin  and  angle  of  jaw 
are  approximated  to  the  fore- 
head. Thus  the  distance  from 
the  tip  of  the  chin  to  the  root 
of  the  nose  measures  only  from 
1^  to  1^  inches. 

The  Sutures  and  Fon- 
tanelles.  —  The  vault  of  the 
sliull  is  made  up  mainly  of  four 
bones,  the  occipital,  the  two 
parietal,  and  the  frontal,  which 
at  the  time  of  birth  is  divided  in  the  median  line  into  two  parts. 
The  squamous  portions  of  the  temporal  bones  form  such  a 
small  proportion  of  the  vault  that  they  scarcely  come  into  con- 
sideration. The  membranous  septa  between  the  bones  are  called 
sutures,  the  points  at  which  two  or  more  sutures  meet  are  called 
fontanelles.  Looldng  at  the  head  from  above  (Fig.  90,  p.  129),  the 
four  sutures  which  are  of  chief  importance  are  seen.  These  are  : — 
1st,  the  sagittal,  which  separates  the  two  parietal  bones,  and  divides 
the  vertex  longitudinally.  It  derives  its  name  sagitta,  an  arrow, 
from  its  appearance  when  the  fcetal  head  is  seen  from  above 
(Fig.  90).  The  anterior  fontanelle,  more  pointed  in  fronc  than 
behind,  is  regarded  as  resembhng  the  head  of  the  arrow,  the  suture 
the  shaft.  2nd.  The  frontal  suture  is  a  continuation  of  the 
sagittal  suture  forwards,  and  separates  the  two  halves  of  the  frontal 
bone.     3rd.     The  coronal  suture   separates   the   frontal  from  the 


Fig.  89.— Foetal  skull,  o— /,  occipito- 
frontal diameter  ;  o — m,  occipito- 
mental ;  m — .r,  maximum  vertico- 
mental  diameter  ;  s — h,  suboccipito- 
bregmatic  ;  s — y,suboccipito-frontal. 


The  Anatomy  of  the  Foetal  Head.        129 

parietal  bones :  it  extends  transversely  and  almost  vertically  across 
the  head,  meeting  at  its  extremities  the  temporal  sutures  at  about 
the  summit  of  the  squamous  portions  of  the  temporal  bones. 
It  receives  its  name  as  marking  about  the  position  at  which 
the  anterior  part  of  the  triumphal  crown  of  the  ancients  rested. 
4th.  The  lamhcloidal  suture  separates  the  angular  projection  of  the 
occipital  bone  from  the  posterior  borders  of  the  two  parietal  bones, 
and  receives  its  name  from  the  resemblance  of  its  shape  to  that  of 
the  Greek  letter  A.  It  extends  at  each  side  to  the  posterior  angle 
of  the  temporal  bone.  The  temporal  sutures,  separating  the  inferior 
concave  borders  of  the  parietal  bones  from  the  squamous  portions 
of  the  temporal  bones,  have  no  practical  obstetric  importance. 


Fig.  90. — Foetal  head  seen  from 
above,  showing  anterior  and 
posterior  fontanelles. 


Fig.  91. — Foetal  skull.  Posterior 
view,  showing  posterior  fonta- 
nelle,  sagittal  and  lambdoidal 
sutures. 


There  are  two  fontanelles  of  importance,  the  anterior  and  posterior. 
The  anterior,  or  greater  fontanelle,  called  also  the  bregma  {^piyixa, 
the  top  of  the  head),  is  formed  by  the  junction  of  the  sagittal, 
frontal,  and  coronal  sutures.  It  forms  a  wide  rhomboidal  mem- 
branous space,  large  enough  for  the  tip  of  the  finger  to  be  laid  in  it ; 
its  anterior  angle  running  between  the  divisions  of  the  frontal 
bone,  extends  much  further  than  the  others  (Fig.  90). 

The  posterior  fontanelle  (Fig.  91)  is  formed  by  the  junction  of  the 
sagittal  and  lambdoidal  sutures.  It  does  not  form  an  open  mem- 
branous space  like  the  anterior,  unless  there  is  defective  ossification, 
but  it  is  recognised  simply  as  the  point  of  junction  of  three  con- 
verging sutures,  the  sagittal  and  the  two  branches  of  the  lambdoidal. 
If  in  any  case  it  should  approximate  in  size  to  the  anterior,  it  is 
easily  distinguished  from  it,  if  it  be  remembered  that  the  anterior 

M.  9 


130  The  Practice  of   Midwifery. 

fontanelle  is  formed  by  the  junction  oifour  sutures  at  right  angles, 
the  posterior  by  the  junction  of  three  sutures,  inclined  at  an  angle 
of  about  120°  to  each  other.  Occasionally,  a  false  fontanelle 
is  formed  by  a  spot  of  defective  ossification  along  the  course  of  one 
of  the  sutures,  generally  the  sagittal.  It  is  distinguished  by  the 
fact  that  only  two  lines  of  suture  can  be  traced  from  it.  Some- 
times mention  is  made  of  temporal  fontanelles,  at  the  anterior  and 
posterior  extremities  of  the  concave  inferior  border  of  each  parietal 
l)one  (Fig.  89,  p.  128).  Of  these,  the  anterior  is  never  of  any  con- 
sequence, being  covered  by  the  temporal  muscle.  The  posterior 
temporal  might  possibly  be  mistaken  for  the  posterior  fontanelle  if 
the  head  were  greatly  flexed,  and  at  the  same  time  flexed  also 
laterally,  so  as  to  bring  its  side  within  reach.  It  would,  however, 
be  readily  distinguished  by  its  being  easy  to  feel  the  ear  in  its 
immediate  proximity. 

Besides  the  change  of  shape  of  the  head  which  is  allowed  by  the 
bending  and  overlapping  of  the  several  bones  forming  the  vault  of 
the  skull,  a  further  moulding  is  permitted  by  the  fact  that  the 
triangular  portion  of  the  occipital  bone,  W'hich  is  a  component  of 
the  vault,  is  united  to  the  basilar  portion,  not  rigidly,  but  by  a 
fibro -cartilaginous  band.  In  this  way  a  kind  of  hinge-joint  is 
formed,  allowing  the  posterior  portions  of  the  bone  to  perform 
movements  of  flexion  and  extension.^ 

The  fcetal  head  often  becomes  unsymmetrical  in  consequence  of 
the  moulding  which  it  undergoes  during  labour.  A  slight  degree 
of  deviation  from  symmetry  may,  however,  be  observed  in  a  foetal 
head  which  has  been  removed  from  the  uterus  either  by  Caesarean 
section,  or  after  the  mother's  death,  and  has  never  undergone  the 
process  of  labour.  This  has  been  ascribed  to  a  natural  asymmetry, 
which  arises  during  development,  and  is  of  such  a  nature  that 
there  is  a  slight  tendency  to  a  spiral  arrangement  throughout  the 
whole  spinal  column,  involving  both  the  head  and  the  pelvis.  So 
far  as  regards  the  head,  it  is  generally  of  such  a  kind  that  the 
right  side  appears  to  be  slightly  displaced  downwards  and  forwards, 
the  left  side  upwards  and  backwards,  in  reference  to  the  vertical 
axis  of  the  foetus.^ 

Diameters  of  the  Foetal  Skull. — In  order  to  judge  of  the 
changes  of  shape  of  the  head,  and  its  relations,  both  before  and 
after  moulding,  to  the  dimensions  of  the  pelvis,  it  is  desirable  to 

1  Budin.  De  la  Tete  du  Foetus  au  Point  de  Vue  de  I'Obstetrique,  Paris,  187(5,  p.  76. 

2  Stadtfeldt,  "On  the  Physiological  Asymmetry  of  the  Head  of  the  Foetus," 
Obstet.  Journ.  VII.,  p,  92. 


The  Anatomy  of  the  Foetal  Head.         131 

have  numerical  measures  of  some  of  the  more  important  diameters 
of  the  skull.  These  have  been  given  very  variously,  and  with  a 
want  of  exactitude,  by  different  authors.  Thus  the  fronto-occipital 
diameter  is  by  some  made  to  terminate  at  the  posterior  fontanelle, 
by  others  at  the  occipital  protuberance.  The  occipito-mental 
diameter  is,  by  different  authors,  regarded  as  starting  from  either 
the  one  or  the  other  of  these  points,  and  is  generally  spoken  of  as 
the  largest  diameter  of  the  skull.  Except  in  a  few  exceptional 
cases,  it  is  nothing  of  the  kind  according  to  either  definition.  The 
maximum  diameter,  in  the  great  majority  of  cases,  runs  from  the 
chin  to  a  point  on  the  sagittal  suture,  somewhat  variable  in  position 
according  to  the  moulding,  but  nearer  to  the  posterior  than  to  the 
anterior  fontanelle.  It  is  usually,  therefore,  a  superoccipito-mental 
diameter.  Exceptionally,  however  (in  some  cases  of  face  and  brow 
presentation),  the  maximum  diameter  terminates  at  a  point  between 
the  posterior  fontanelle  and  the  occipital  protuberance,  and  is, 
therefore,  a  suboccipito-mental  diameter.  It  appears  better,  there- 
fore, with  Budin,^  to  describe  a  maximum  vertico-mental  diameter, 
as  distinct  from  the  occipito-mental.  Again,  the  cervico-bregmatic 
and  suboccipito-bregmatic  diameters  are,  by  different  authors,  made 
to  terminate  at  the  centre  of  the  anterior  fontanelle,  its  anterior 
margin,  or  a  point  on  the  sagittal  suture.  For  these  diameters  to 
be  of  any  use  in  giving  information  as  to  the  moulding  of  the  head, 
it  is  absolutely  necessary  that  they  should  be  measured  from  points, 
such  as  the  centres  of  the  fontanelles,  which  can  be  accurately 
determined  throughout  all  stages  and  varieties  of  moulding.  The 
important  diameters,  then,  are  the  following  (see  Fig.  89,  p.  128) : — 
1st,  the  maximum  vertico-mental  (Max.) ;  2nd,  the  occipito-mental 
(O.M.),  measured  from  the  posterior  fontanelle  to  the  chin  ;  3rd, 
the  occipito-frontal  (O.F.),  measured  from  the  posterior  fontanelle 
to  the  glabella,  or  root  of  the  nose^ ;  4th,  the  cervico-bregmatic  (C.B.), 
measured  from  the  centre  of  the  foramen  magnum  to  the  centre  of 
the  anterior  fontanelle,  or  point  of  intersection  of  the  coronal  with 
the  line  of  the  sagittal  and  frontal  sutures ;  5th,  the  suboccipito- 
bregmatic  (S-0.  B.),  measured  from  the  junction  of  the  occipital 
bone  with  the  back  of  the  neck  to  the  centre  of  the  anterior 
fontanelle ;  6th,  the  suboccipito-frontal  (S-0.  F.),  measured  from 
the  same  point  to  the  prominence  of  the  forehead.  All  these  are 
measured  in  the  vertical  antero-posterior  plane.  The  following  are 
transverse  diameters : — 7th,  the  bi-parietal  (Bi-P.),   or  maximum 

1  Of).  f;it.,  p.  17. 

2  This  measurement  is  moie  commonly  taken  to  the  occipital  protuberance,  but  in 
the  unmoulded  head,  its  magnitude  is  about  the  same  in  either  case.  The  position  of 
the  occipital  protuberance  cannot  be  precisely  determined  in  the  living  infant. 

9—2 


132  The  Practice  of   Midwifery. 

transverse,  between  the  two  parietal  protuberances  ;  8th,  the  bi- 
temporal (Bi-T.)  is  measured  between  the  points  widest  apart  on 
the  coronal  suture ;  9th,  the  bi-zygomatic  (Bi-Z.),  or  minimum 
transverse  diameter  of  the  base  of  the  skull,  is  measured  between 
the  two  points  widest  apart  on  the  zygomata  ;  10th,  the  bi-mastoid 
(Bi-M.),  the  outside  diameter  between  the  mastoid  processes  at  their 
widest  part.-^  Of  these  diameters  the  cervico-bregmatic  corresponds 
approximately  with  the  vertical  diameter  of  the  skull.  The  occipito- 
frontal does  not  perfectly  correspond  with  an  antero-posterior  or 
longitudinal  diameter,  which  should  be  rather  measured  from  the 
occipital  protuberance  than  from  the  posterior  fontanelle.  In  the 
unmoulded  head  the  two  are  almost  precisely  equal,  but  in  the 
ordinary  moulding  of  vertex  presentations  the  occipito-frontal 
becomes  the  larger.  Owing  to  the  flexed  position  of  the  head, 
neither  the  one  nor  the  other  is  normally  ever  coincident  with  the 
plane  of  the  pelvic  brim. 

The  following  are  average  measurements  for  these  diameters  in 
the  unmoulded  head,  those  in  the  second  column  being  given  to  the 
nearest  quarter  of  an  inch,  as  as  to  be  more  easily  committed  to 
memory : — 

1.  Maximum  vertico-mental  diameter  (Max.) 

2.  Occipito-mental  (O.M.)    . 

3.  Occipito-frontal  (O.F.)     . 

4.  Cervico-bregmatic  (C.B.) 

5.  Suboccipito-bregmatic  (S-0.  B.) 

6.  Suboccipito-frontal  (S-0.  F.)    . 

7.  Bi-parietal  (Bi-P.)    . 

8.  Bi-temporal  (Bi-T.) 

9.  Bi-zygomatic  (Bi-Z.) 
10.  Bi-mastoid  (Bi-M.) 

The  plane  of  the  head  corresponding  to  the  suboccipito-bregmatic 
diameter  has  a  circumference  on  an  average  of  12i  inches,  or  32  cm., 
that  corresponding  to  the  occipito-frontal  diameter  of  13f  inches, 
or  34cm.,  and  the  circumference  corresponding  to  the  occipito-mental 
measures  about  14  or  14^-  inches,  or  35  to  36  cm. 

After  even  easy  labours,  with  normal  vertex  presentation,  the 
diameters  of  the  head  will,  when  the  child  is  born,  be  somewhat 
different  in  relative  magnitude  from  those  given  above,  in  conse- 
quence of  the  pressure  which  the  head  has  sustained.     The  most 

1  A  fronto-mental  diameter  is  sometimes  mentioned,  and  estimated  at  about 
3  25  inches,  but  this  is  useless,  since  there  is  no  definite  point  from  which  to  measure 
its  upper  extremity. 


ins. 

cm. 

(Max.)     5 

or  5    =  12-5 

.     4-85 

„  4|  =  12 

.     4-6 

„  41  =  11-25 

.     3-8 

„  3|  =    9-5 

.     3-8 

„  3f  =    9-5 

.     4-1 

„  4    =10 

.     3-7 

„  3|  =    9-5 

.     3-4 

„  31  =    8-25 

.     3-1 

„  3    =    7-5 

.     3-0 

„  3    =    7-5 

The  Anatomy  of  the  Foetal  Head.        133 

marked  changes  are  increase  of  the  maximum  vertico-mental 
diameter,  and  diminution  of  almost  all  the  rest,  even  of  the  occipito- 
mental, but  especially  of  the  suboccipito-bregmatic  and  bi-parietal. 
The  nature  of  the  moulding  will  be  explained  in  the  chapter  on  the 
mechanism  of  labour. 

The  compressibility  of  the  trunk  of  the  foetus  is  so  marked  that 
the  diameters  are  of  little  importance.  The  longest  transverse 
diameter  of  the  shoulders  measures  about  4-|  inches,  or  12  cm.,  and 
can  be  reduced  by  pressure  by  nearly  f  inch,  or  2  cm.,  and  that  of 
the  pelvis,  the  bis-iliac,  about  3J  inches,  or  8  cm. 

Influence  of  Sex  and  Race  on  the  Dimensions  of  the  Foetal 
Head. — The  brain  of  men  being,  on  the  average,  somewhat  more 
bulky  than  that  of  women,  there  is  a  corresponding  difference  in  the 


Fig.  92. — Skull  of  a  European  foetus. 


Fig.  93.— Skull  of  a  Negro  foetus. 


size  of  the  head  of  male  and  female  children  at  birth.  The  average 
difference  in  circumference  has  been  found  to  be  about  half  an  inch, 
or  about  one  twenty-fifth  part  of  the  whole.  The  bones  of  the  male 
skull  are  also  generally  more  firmly  ossified  at  the  time  of  birth. 
Hence  arises  greater  protraction  of  labour  in  the  case  of  males,  more 
frequent  necessity  for  artificial  aid,  and  greater  mortality  both  to 
mothers  and  children.  Thus,  out  of  more  than  47,000  deliveries 
in  the  Guy's  Hospital  Lying-in  Charity,  the  number  of  children 
stillborn  was,  including  all  presentations,  among  males  42*8  per 
1,000,  among  females  35"6  per  1,000  ;  while,  in  vertex  presentations 
at  full  term,  the  numbers  were,  among  males  26'9  per  1,000, 
among  females  21*5  per  1,000  stillborn.  A  greater  number 
of  male  children  than  females  also  die  shortly  after  birth.  The 
size  of  the  child's  head,  like  its  total  bulk,  increases  with  the  age 
and  repeated  pregnancies  of  the  mother,  in  the  mode  which  has 
been  already  mentioned  (see  p.  120). 


134  "The  Practice  of   Midwifery, 

The  influence  of  race  is  a  still  more  important  one  than  that  of 
sex.  The  increase  of  size  in  the  brain  which  goes  with  civilisation 
and  intellectual  development  involves  greater  pain,  difficulty,  and 
risk  in  parturition,  for  it  requires  a  corresponding  increase  of  size 
in  the  skull,  and  although ;the  pelvis  undergoes  some  corresponding 
enlargement,  yet  this  does  not  fully  keep  up  with  that  of  the  head. 
In  savage  races  not  only  is  the  head  smaller  on  the  whole,  but  there 
is  relatively  less  development  of  the  anterior  cerebral  lobes,  and  the 
forehead  is,  therefore,  flatter.  The  suboccipito-frontal  diameter 
(3,  4,  Figs.  92,  93),  therefore,  and  also  a  diameter  passing  through 
the  prominence  of  the  forehead  parallel  to  the  suboccipito-breg- 
matic,  are  much  smaller.  Labour  is,  therefore,  facilitated  in 
corresponding  degree,  since  this  latter  diameter,  in  the  living  child, 
has  to  be  taken  in  conjunction  with  a  portion  of  the  back  of  the 
neck,  when  the  head  is  entering  the  pelvis  well  flexed,  and  thus 
becomes  the  largest  of  all  the  diameters  of  the  foetus  which  is  ever 
coincident  with  the  greatest  diameters  of  the  pelvic  brim  or  outlet. 
In  explaining  the  facility  of  parturition  in  savage  women,  it  is 
necessary  also  to  take  into  account  the  greater  sensibility  to 
pain  induced  by  the  mode  of  life  of  the  civilised  and  highly 
cultivated  woman,  although  the  difference  in  the  size  of  the 
foetal  head  appears  to  be  the  most  important  element.  Even  in 
the  same  race,  the  size  of  the  head  is  greater  in  the  educated 
classes  than  in  the  uneducated,  the  greater  also  among  inhabit- 
ants of  towns  than  in  agricultural  districts.  Comparing  civilised 
races  with  each  other,  difficult  labours  are  perceptibly  more 
numerous  in  a  race  like  the  Teutonic,  in  which  the  type  of  head 
is  short  and  round,  or  brachycephalic,  than  in  one  like  the  Celtic, 
Scandinavian,  or  Norman,  in  which  it  is  more  frequently  long  or 
dolichocephalic.  Some  savage  races,  like  the  Caribs,  and  the 
Macrocephali,  a  Scythian  race  mentioned  by  Hippocrates,  have 
been  accustomed  to  flatten  the  foreheads  of  the  children  by  pres- 
sure in  early  infancy,  and  it  has  been  supposed  that  a  hereditary 
tendency  to  such  a  form  of  head  has  eventually  been  acquired  in 
such  cases.  This,  however,  would  be  opposed  to  the  modern 
doctrine  that  acquired  characters  are  not  inherited. 


Articulation  of  the  Foetal  Head. — The  articulation  of  the 
head  with  the  spinal  column,  allowing  movements  of  flexion  and 
extension,  is  situated  nearer  to  the  occiput  than  to  the  forehead,  in 
the  proportion  of  about  one  to  two.  The  head,  balanced  upon  its  con- 
dyles, may  hence  be  regarded  as  a  lever,  the  anterior  arm  of  which 


The  Anatomy  of  the  Foetal  Head.         135 

is  longer  than  the  posterior.  The  importance  of  this  circumstance, 
in  securing  flexion  of  the  head,  will  be  seen  hereafter  (Fig.  153, 
p.  245).  The  extensive  movements  of  the  head  which  are  possible 
in  the  fcetus  are  due  to  the  extreme  flexibility  of  the  cervical  portion 
of  the  vertebral  column.  Movements  of  rotation  take  place  between 
the  atlas  and  axis,  and  the  head  can  generally  be  rotated  upon  the 
body  through  as  much  as  a  quarter  of  a  circle  without  injury  to  the 
spinal  cord. 


Chapter  VIL 

THE   ATTITUDE,   PRESENTATION,   LIE,    AND 
POSITION  OF   THE    FCETUS    IN   UTERO, 

By  the  attitude  of  the  foetus  is  meant  the  relation  which  the 
different  j)arts  of  its  body  have  to  each  other.  By  the  presentation 
is  meant  the  part  of  its  body  which  occupies  the  lower  segment 
of  the  uterus,  lying  over  the  internal  os  uteri.  This  must 
be  distinguished  from  the  presenting  part,  or  that  part  of  the 
foetus    which   is    felt   by    the   finger   when   passed   through    the 


Fig.  94. — Attitude  of  the  mature  foetus  in  utero. 

cervical  canal.  The  word  lie  is  used  to  denote  the  relation  of  the 
long  axis  of  the  foetus  to  the  axis  of  the  uterus.  Thus  the  lie 
may  be  longitudinal,  oblique,  or  transverse.  By  the  position 
is  meant  the  relation  which  some  part  of  the  foetus  {e.g.,  the  back) 
has  to  the  front,  back,  and  sides  of  the  uterine  walls.  Thus  the 
back  may  be  inclined  backward  or  forward,  to  the  right  or  to 
the  left.  Hence  for  each  presentation  or  lie  of  the  foetus  there 
are  varying  positions,  and  it  is  usual  to  divide  these  into   four, 


Attitude  of  the  Foetus  in  Utero. 


137 


with  reference  to  two  axes  or  straight  lines  intersecting  the  longi- 
tudinal axis  of  the  uterus  at  right  angles  to  that  axis  and  to  each 
other,  and  thus  dividing  the  uterus,  or  the  pelvic  brim,  into  four 
compartments.  The  corresponding  positions  are  called  the  first, 
second,  third,  and  fourth,  and  will  be  described  hereafter  in 
reference  to  each  presentation. 

Attitude. — The   usual    attitude    of    the    foetus    is    as    follows 
(Fig.  95): — The  back  is  arched,  so  as  to  form  a  convexity  backward. 


Fig.  95. — Normal  attitude  of   the  fcetus  in  utero.     (Bumm,  Grundriss  der 
Geburtshilfe.) 


The  head  is  bent  upon  the  sternum,  and  is  usually  inclined 
to  one  or  other  shoulder.  The  forearms  are  crossed,  or  close 
to  each  other  in  front  of  the  chest.  The  thighs  and  legs  are 
flexed,  so  that  the  knees  are  near  the  elbows  and  the  heels  near 
the  breech  or  buttocks,  the  dorsum  of  the  foot  being  drawn  up 
toward  the  leg,  and  the  sole  turned  somewhat  inward.  The  legs 
are  generally  crossed.  The  umbilical  cord  generally  lies  in  the 
space  between  the  arms  and  legs  (Fig.  94).  This  attitude  exists  more 
or  less  from  the  early  part  of  pregnancy,  but  varies  somewhat  with 
the  amount  of  liquor  amnii.  Thus  when  the  liquor  amnii  is  relatively 
in  greater  quantity  the  limbs  have  greater  freedom  of  movement, 


iss 


The  Practice  of   Midwifery. 


and  are  not  so  close  to  the  body  (Fig.  96).  The  attitude  is  due 
to  the  tonic  action  of  the  flexor  muscles,  which,  as  being  the 
stronger,  predominate  over  the  extensors.  Any  persistent  deviation 
from  the  normal  attitude  occurs  as  a  rule  only  in  dead  children. 
A  tendency  toward  a  similar  position  of  the  limbs  is  seen  in  the 
infant  even  after  birth.  At  the  very  earliest  stage  of  pregnancy 
the  embryo  hangs  by  the  umbilical  cord,  not  touching  the  walls  of 


Fig.  96. — Attitude  of  foetus  wt  utero  with  abundant  liquor  amnii.  (Bumm, 
modified  from  Chievitz.,  A  Research  on  the  Topographical 
Anatomy  of  the  Full  Term  foetus  in  sitw,  1899.) 

the   ovum,   with   its   back  downward,    and  its  cephalic  extremity 
somewhat  lower  than  the  other. 


Presentation  and  Lie. — With  regard  to  its  presentation  or  lie 
the  fcetus  in  the  great  majority  of  cases  lies  with  its  head  down- 
ward and  with  its  long  axis  coincident  with  that  of  the  uterus,  that 
being  the  position  in  which  its  shape  is  most  conveniently  adapted 
to  the  shape  of  the  uterine  cavity,  which  is  most  spacious  at  the 
fundus  (see  Fig.  97,  p.  140).     At  the  end  of  pregnancy  the  propor- 


Presentation  of  the  Foetus  in  Utero.      139 

tion  of  cephalic  presentations  is  as  much  as  96  per  cent.  In  the 
Guy's  Hospital  Lying-in-Charity,  out  of  23,800  children,  it  was 
96*9  per  cent.  It  was  for  a  long  time  believed  that  up  to  about  the 
seventh  month  of  pregnancy  the  fcetus  lay  with  its  head  uppermost, 
and  that  then  by  an  active  movement  of  its  own,  which  was  called 
the  culbute,  it  suddenly  reversed  its  position.  It  is  now  established 
that  the  head  is  generally  lower  than  the  breech,  even  from  the 
commencement  of  pregnancy.  In  the  earlier  months  frequent 
changes  of  jDOsition  take  place  through  the  foetal  movements,  and 
even  up  to  the  later  months  the  proportion  of  head  presentations 
is  not  so  great  as  at  full  term.  Thus  Veit  at  the  seventh  month 
of  pregnancy  found  56*6  per  cent,  vertex,  38"4  per  cent,  breech,  and 
4'8  per  cent,  transverse  presentations. 

According  to  Churchill,  at  the  seventh  month  the  proportion  of 
head  presentations  is  among  living  children  only  83  per  cent.,  and 
among  dead  children  only  53  per  cent.  Dubois  gives  88  per  cent, 
as  the  proportion  of  head  presentations  for  living  children,  and 
only  45  per  cent,  for  dead  children,  born  during  the  seventh  month. 

With  the  advance  of  pregnancy  the  frequency  of  head  presenta- 
tions markedly  increases.  Thus  Simpson  found  at  the  eighth  month 
68  per  cent.,  at  the  ninth  month  76  per  cent.,  and  at  full  term  96 
per  cent,  cephalic  presentations. 

Collins,  in  about  16,000  deliveries,  found  the  proportion  of  head 
presentations  among  living  children  98'3  per  cent.,  among  children 
born  in  a  putrid  state,  upwards  of  500  in  number,  only  80  per  cent. 
These  figures  show  also  that  the  proportion  of  head  presentations 
is  much  less  among  dead  children  than  among  living  at  the  same 
period  of  pregnancy. 

Changes  from  other  presentations  into  head  presentations  are 
more  frequent  than  the  converse,  and  a  transverse  or  oblique  is 
more  frequently  changed  than  a  breech  presentation.  Although 
changes  from  the  head  into  a  breech  or  transverse  presentation  are 
relatively  more  rare,  yet  they  do  not  infrequently  occur.  According 
to  Schroeder,  the  former  occur  in  8*3  per  cent,  of  all  cases,  and  a 
fcetus  has  been  observed  to  change  its  position  from  head  to  breech 
and  vice  versa  as  many  as  six  times  within  a  few  days.  The  chief 
causes  of  such  changes  are  strong  movements  of  the  foetus  occurring 
in  conjunction  with  a  changed  posture  of  the  mother.  Valenta, 
from  repeated  observations  made  on  nearly  1,000  pregnant  women, 
found  that  changes  of  presentation  occurred  in  42*4  per  cent,  in  the 
later  months  of  pregnancy.^     Fasbender^  in  418  cases  examined 

1  Monatsschrift  f.  Geburt,  1866. 

2  Beitrage  z.  Geburtsh.  u.  Gyn.,  1870,  Bd.  1,  Heft  1,  540. 


140 


The  Practice  of   Midwifery. 


during  the  last  two  to  three  months  of  pregnancy  observed  changes 
of  position  in  88,  or  21  per  cent.,  and  changes  of  presentation 
in  75,  or  18  per  cent.  The  presentation  becomes  progres- 
sively more  stable  as  the  end  of  pregnancy  approaches,  more 
especially  in  primiparae,  in  whom  the  head  rests  lower  in  the  pelvis, 
while  the  firmer  abdominal  walls  prevent  much  swaying  over  of  the 
fundus  uteri  as  the  position  of  the  body  is  changed.  Schroeder, 
from  observation  on  214  primiparae  (including  four  cases  of 
contracted  pelvis)  during  the  last  three  weeks  of  pregnancy,  found 

that  changes  of  presentation  took  place 
in  36*4  per  cent.  The  instability  of  the 
presentation  is  much  greater  when  any 
deformity  of  the  mother  exists,  especially 
when  there  is  a  contracted  pelvis,  which 
keeps  the  fcetal  head  entirely  above  the 
brim. 

Causation  of  Head  Presentation.  — 
There  are  three  chief  causes  to  which 
the  preponderating  frequency  of  head 
IDresentation  is  to  be  attributed :  1st,  the 
efi'ect  of  gravity ;  2nd,  the  adaptation  of 
the  shape  of  the  foetus  to  that  of  the 
uterine  cavity;  and  3rd,  the  effect  of 
foetal  movements  excited  by  pressure 
when  the  two  shapes  do  not  correspond. 
Some  controversy  has  taken  place  as  to 
which  of  these  is  the  true  cause,  but  the 
more  correct  view  is  to  regard  them  all 
as  having  an  influence.  As  the  foetus  is 
immersed  in  fluid  not  much  lighter  than 
itself,  the  effect  of  gravity  will  depend, 
not  upon  the  position  of  its  centre  of  gravity  when  in  air,  but  upon 
the  relative  specific  gravity  of  its  different  parts.  Matthews  Duncan 
has  shown  that  the  specific  gravity  of  the  foetal  head  is  greater  than 
that  of  the  decapitated  trunk,  and  that,  when  the  foetus  is  immersed 
in  saline  fluid  of  about  the  same  specific  gravity  as  itself,  it  lies  in  an 
oblique  position,  its  head  lower  than  the  breech,  and  the  right  side 
lowest  owing  to  the  weight  of  the  liver.  If  allowed  to  sink,  the  right 
shoulder  generally  touches  the  bottom  first.  Within  the  uterus  the 
foetus  is  not  suspended  by  the  umbilical  cord,  except  at  the  very 
earliest  stage  of  pregnancy,  but  rests  on  the  inclined  plane  formed 
by  the  uterine  wall.  When  the  woman  is  standing  upright  it  rests 
on  the  anterior  uterine  wall,  inclined  to  the  horizon  at  an  angle  of 


Fig.    97.— Outline    of     the 
uterus  at  full  term. 


Presentation  of    the  Foetus  in  Utero.       141 

about  35°,  the  normal  pelvic  inclination  being  somewhat  diminished 
during  pregnancy  in  order  to  preserve  the  balance  of  the  body.  In 
these  circumstances  the  usual  position  of  the  foetus  is  almost  exactly 
that  which  it  assumes  when  immersed  in  saline  fluid.  Again,  when 
the  woman  is  lying  flat  on  her  back,  the  fcetus  rests  on  the  posterior 
uterine  wall,  inclined  at  an  angle  of  about  55°  to  the  horizon.  In 
this  position  also  gravity  favours  head  presentation,  but  tends  to 
rotate  the  back  of  the  foetus  towards  the  mother's  back.  In  the 
reclining  position,  when  the  shoulders  are  raised,  the  axis  of  the 
uterus  is  nearly  vertical,  and  the  higher  specific  gravity  of  the  head 


Fig.  98.— Ovoid  form  of  foetus  at 
full  term. 


Fig.  99. — Adaptation  of    foetus 
to  uterus. 


tends  still  further  to  keep  it  over  the  os.  When,  however,  the 
woman  lies  on  her  side,  the  fundus  uteri  drops  over  by  its  own 
weight,  and  then  gravity  tends  to  displace  the  head  from  the  os. 
The  gravitation  theory  accounts  for  head  presentations  being  less 
usual  with  dead  children,  for  Matthews  Duncan  found  that  where  the 
child  had  died  in  utero  before  labour,  the  specific  gravity  of  the  head 
was  less  than  in  the  case  of  a  living  child,  and  the  foetus  often  floated 
with  the  head  highest  in  a  saline  fluid  of  its  own  specific  gravity. 
These  experiments  of  Matthews  Duncan,  however,  are  taken 
exception  to  by  Schatz  ^  and  Whitridge  Williams,  who  have  shown 
that  when  the  fluid  in  which  the  foetus  is  suspended  has  a  specific 


1  Schatz,  Arch.  f.  Gynak.,  1904,  Heft  3,  LXXI.,  s.  541. 


142 


The  Practice  of   Midwifery. 


gravity  nearly  approximating  to  that  oi:  the  liquor  amnii,  or  from 
1,010  to  1,020,  the  breech  tends  to  sink  rather  than  the  head.  Seitz,^ 
too,  has  found  that  the  specific  gravities  of  the  head  and  of  the 
decapitated  trunk  are  the  same,  and  that  the  former  is  not  higher 
than  the  latter,  as  Matthews  Duncan  supposed. 

In  cases  of  hydrocephalus  breech  presentations  occur  in  29  per  cent, 
of  the  cases,  or  about  nine  times  as  frequently  as  they  do  with 
healthy  children.  This  is  explained  in  a  measure  by  the  fact  that 
the  specific  gravity  of  the  hydrocephalic  head  is  probably  less  than 
that  of  the  healthy  head  notwithstanding  the  increase  of  its  total 


Fig.  100. — Adaptation  of  hydro- 
cephalic foetus. 


Fig.  101. — Diagram  of  maladaptation 
of  foetus  and  uterus  in  breech 
presentation. 


weight.  In  this  case,  however,  the  question  of  adaptation  of  shape 
comes  also  into  play  :  the  enlarged  head  does  not  so  readily  fit  into 
the  lower  segment  of  the  uterus  ;  and  when  the  enlargement  is  very 
great,  the  shape  of  the  foetus  may  be  best  adapted  to  that  of  the 
uterus  when  the  head  is  uppermost  (see  Fig.  100).  Another  reason 
for  thinking  that  the  effect  of  gravity  is  not  sufficient  by  itself  to 
account  for  all  the  circumstances  is  found  in  the  fact  that  the  head 
presents  more  frequently  than  other  parts,  even  when  women  are 
constantly  lying  in  bed,  and  as  frequently  on  the  side  as  on  the 
back. 

A  much  more  important  factor  in  all  probability  is  the  adaptation 
of  the  shape  of  the  foetus  to  that  of  the  uterus.     In   the   later 

1  Seitz,  von  Winckel's  Handbuch  der  Geburtshlilfe,  1904,  Vol.  1.,  p.  1012,  Part  II. 


Presentation  of  the  Foetus  in  Utero. 


143 


months  of  pregnancy  the  shape  of  the  uterine  cavity  is  definitely 
pyriform,  with  the  hroad  end  uppermost  (see  Fig.  97,  p.  140), 
and  this  is  especially  the  case  when  its  walls  become  rigid  under 
the  influence  of  the  occasional  muscular  contractions  which 
are  constantly  taking  place  throughout  pregnancy.  The  shape  of 
the  foetus  in  its  usual  attitude  is  also  pyriform,  and  corresponds  to 


..«*.*>:  -^>' 


Fig. 


102. — -Foetus   in  utero  at   the  fifth   month   presenting  by  the  breech. 
(Modified  from  specimen,  Mus.,  Univ.  Coll.  Hosp.  Med.  School.) 


that  of  the  uterus  when  the  head  is  downwards.  When  the  long 
axis  of  the  child  is  transverse  or  oblique,  the  pressure  of  the  con- 
tracting uterine  wall  tends  to  press  the  projecting  poles  towards  the 
central  axis  of  the  uterus,  and  so  convert  the  presentation  into  a  head 
or  breech.  At  the  same  time  the  pressure  thus  exerted  upon  the 
fcetus  is  likely  to  excite  reflex  movements,  which  assist  in  changing 
the  position.  In  breech  presentations  (Fig.  101,  p.  142),  the  foetus 
is  not  BO  well  adapted  to  the  uterine  cavity  as  in  cephalic,  the  lower 


144  The  Practice  of   Midwifery. 

segment  of  the  body  of  the  uterus  being  unduly  distended.  It  is 
not  Hkely  that  the  uterine  contractions  would  by  themselves  change 
such  a  presentation,  but  the  foetus  is  not  so  stably  held  in  position 
by  the  uterine  walls  as  when  the  head  is  downwards,  and  it  is  probable 
that  the  increased  pressure  on  the  legs  may  excite  more  lively 
movements  than  usual,  and  increase  the  chances  of  a  change  of 
presentation.  Such  movements  of  the  lower  limbs,  too,  are  likely  to 
produce  a  greater  effect,  since  they  will  act  against  the  bones  of  the 
pelvis  and  not  against  the  soft  tissues  of  the  fundus  uteri.  All 
changes  occur  more  easily  when  the  liquor  amnii  is  relatively 
abundant,  and  after  the  rupture  of  the  membranes  it  is  rare  for  a 
change  of  presentation  to  occur.  That  such  a  thing  is  a  possibility, 
however,  is  shown  by  the  occurrence  of  the  so-called  spontaneous 
version  in  some  cases  of  shoulder  presentation. 

When  the  child  is  dead  the  effect  of  reflex  movements  is  lost,  and 
the  long  axis  of  the  child  has  no  longer  the  same  tonicity.  These 
influences  must  be  added  to  that  of  the  changed  specific  gravity  of 
the  head  in  accounting  for  the  frequency  of  abnormal  presenta- 
tions with  dead  children.  In  the  earlier  months  of  pregnancy  the 
uterine  cavity  is  more  spherical,  and  the  relative  abundance  of 
liquor  amnii  allows  the  foetus  to  lie  in  it  in  almost  any  position  (see 
Fig.  102).  An  abnormal  presentation  is  also  more  easily  produced, 
by  the  gush  of  liquor  amnii  on  rupture  of  the  membranes, 


Chapter  VIII. 

CHANGES   IN  THE  MATERNAL  ORGANISM  CONSE- 
QUENT  UPON    PREGNANCY. 

Changes  in  the  Uterus. — From  the  commencement  of  preg- 
nancy an  increased  nutritive  energy  is  imparted  to  the  sexual 
apparatus,  including  the  breasts,  and  to  surrounding  parts,  but 
more  especially,  and  in  enormous  degree,  to  the  body  of  the  uterus, 
which  serves  as  a  receptacle  for  the  ovum.  The  nulliparous 
uterus  weighs  about  an  ounce  (30  gms.),  that  of  the  woman  who 
has  borne  children  about  IJ  ounces  (45  gms.) ;  at  the  full  term  of 
pregnancy  it  weighs  28  ounces  to  2  pounds,  or  about  1,000  gms., 
not  including  the  blood  contained  in  its  walls,  while  the  foetus  is 
still  in  its  cavity. 

The  length  of  the  uterine  body  is  increased  from  about  If  inches, 
or  4  cm.,  in  the  nullipara  to  about  12  inches,  or  30  cm. ;  its  width 
from  If  inches,  or  3*5  cm.,  to  about  9  inches,  or  22"5  cm. ;  and  its 
depth  from  about  1^  inches,  or  3  cm.,  to  about  8  inches,  or  20  cm. 

The  cavity,  which  in  the  nulliparous  uterus  is  almost  flattened, 
and  has  cubical  capacity  only  sufficient  to  contain  a  few  drops  of 
mucus,  is  increased  at  its  full  development  some  519  times  (Krause). 
The  following  table  gives  the  average  dimensions  of  the  uterus  as 
a  whole  at  different  months  according  to  Farre  and  Tanner^  in 
inches,  and  according  to  Waldeyer^  in  centimetres  : — 


Length.  Width.  Depth, 

ins.  cms.  ins.         cms.         ins.  cms. 

End  of  3rd  month  4^-  5  =  13  4    =  8-8-5      3=8 
4th 
5th 

6th       „       8  -  9  =  21-5  6|  =  17-5        6    =  16 

10  -11  =  27-30  7^  =  20  61  =  17-5 

11  -12  =  30-32-5  8    =  21-5        7    =  19-5 


7th 
8th 
9th 


51-  6  =  13-5  5  4 

6  -  7  =  17  5*  5 


12  -14  =  32-5-37-5  9|  =  25-5    8-9    =  21*5-24-5 


This  growth  affects  all  the  elements  of    the  uterus — the  mucous 
membrane,  the  muscular  walls,  the  peritoneal  covering,  the  arteries, 

1  Cyclopaedia  of  Anatomy  and  rhysiology  :   article,  "  Uterus  and  its  Appendages," 
p.  645. 

2  Waldeyer,  Das  Beckcu,  Bonn,  IH'J'.), 

M.  10 


146 


The  Practice  of   Midwifery. 


veins,  nerves,  and  lymphatics.  The  growth  of  the  mucous 
membrane  by  which  the  decidua  is  formed  has  ah*eady  been 
described.  The  increase  of  the  area  of  the  muscular  wall  is  in 
great  measure  due  to  growth  rather  than  distension  by  the  ovum 
within  the  first  three  months  of  pregnancy,  for  at  this  time  the 
uterine  cavity  is  not  completely  filled  by  the  ovum,  and  an  almost 
corresponding  growth  of  the  uterus  takes  place  in  the  early  part  of 

pregnancy  in  cases  of  extra-uterine 
fcetation,  when  the  ovum  is  not 
inside  the  uterine  cavity.  It  is 
brought  about  by  the  general 
systemic  changes  induced  by  the 
pregnancy  itself. 

In  the  later  months  distension 
has  more  influence,  and  the  mus- 
cular wall  no  longer  increases  in 
thickness,  but  becomes  somewhat 
thinner  than  before.  Its  thickness 
at  full  term  varies  much  in 
different  cases,  nnd  thus  accounts 
for  great  varieties  in  the  expulsive 
power  of  the  uterus.  It  generally 
varies  from  J  to  f  inch  (5-10  mm.), 
except  over  the  placental  site, 
where  it  is  greater. 

A  marked  change  in  the  tissue 
of  the  muscular  wall  takes  j)lace 
by  the  development  of  enormous 
involuntary  muscular  fibres,  often 
as  much  as  ten  times  the  length 
and  five  times  the  thickness  of 
those  seen  in  the  unimpregnated 
uterus.  These  may  arise  in  part 
by  the  growth  of  the  original  mus- 
cular fibres,  but  partly  also  by  the 
development  during  the  first  twenty-six  weeks  of  the  embryonic 
nucleated  muscular  fibre-cells,  having  a  length  not  much  greater 
than  their  thickness,  which  exist  in  the  unimj)regnated  uterus. 
These  are  showm  at  1,  2,  in  Fig.  103,  and  the  process  of  development 
of  the  large  fibres  at  3,  4,  5.  The  length  of  the  developed  fibres 
is  as  much  as  ^q  or  Jq  inch. 

The  connective  tissue  in  the  wall  of  the  uterus  develops  with  the 
muscle  fibres,  and  becomes  softer  and  more   spongy  in  texture. 


Fig.  103. — 1,2,  Embryonic  nucleated 
muscular  fibre-cells  of  the  unim- 
pregnated uterus.  3,  4,  5,  Mus- 
cular fibre-cells  of  the  gravid 
uterus  in  different  stages  of  deve- 
lopment. 


Changes  in  the   Maternal   Organism.        147 

There  is  a  considerable  increase  in  the  number  of  yellow  elastic 
fibres,  which  is  most  marked  between  the  muscle  fibres  of  the 
external  and  middle  layers,  and  around  the  vessels.     In  the  cervix 


Fig.  104. — Drawing  of  elastic  fibres  in  the  wall  of  the  pregnant  uterus 
showing  their  marked  development  under  the  peritoneum  in  the  outer 
and  middle  layers  of  muscle  tissue  and  around  the  vessels  of  the  uterine 
wall. 

there  is  a  similar  layer  superficially  under  the  epithelium   and  a 
deeper  layer  surrounding  the  vessels. 

The  distribution  of  muscular  fibres  in  the  unimpregnated  uterus 
is  confused,  so  that  no  definite  layer  or  arrangement  can  easily  be 


Fig.  105. — Diagram  of  external  layer  of 
muscle  fibres  of  pregnant  uterus. 


Fig.  106. — Diagram  of  middle  layer  of 
muscle  fibres  of  pregnant  uterus. 


made  out.  At  the  full  term  of  pregnancy  three  muscular  layers  are 
described,  but  these  are  not  so  definite  or  so  easily  separable  as  the 
circular  and  longitudinal  layers  forming  the  walls  of  other  hollow 
viscera,  as  the  intestines.  The  external  layer  continuous  with  the 
outer  longitudinal  layer  in  the  wah  of  the  Fallopian  tube  forms  a 
subserous  layer  which  spreads  out  over  the  fundus  of  the  uterus, 

10—2 


148 


The  Practice  of   Midwifery. 


passing  down  as  longitudinal  bands  over  its  anterior  and  posterior 
surfaces,  and  sends  some  fibres  into  the  broad  ligaments  (Fig.  105). 
The  middle  layer  is  the  thickest  and  strongest,  especially  towards 
the  fundus  of  the  uterus.  It  consists  of  fibres  which  interlace  in 
various  directions  and  surround  the  uterine  arteries.  They  must 
therefore  diminish  the  calibre  of  the  arteries  by  their  contraction  ; 
and  when  the  emptying  of  the  uterus  allows  a  more  complete 
retraction  of  the  fibres  and  shrinking  of  the  uterine  wall,  they  close 
the  canals  of  the  vessels  entirely,  and  so  prevent  haemorrhage  after 
the  separation  of  the  placenta.  This  layer  is  continuous  with  the 
circular  fibres  in  the  wall  of  the  tube,  and  is  reinforced  by  fibres 
derived  from  the  round  ligaments,  the  ovarian  ligaments,  and 
especially  the  utero-sacral  ligaments  (Fig.  106).    The  fibres  from  the 

latter,  together  with  the  trans- 
verse bands  of  the  circular 
fibres  derived  from  the  tube, 
make  up  the  greater  part  of 
the  middle  layer. 

The  internal  layer  is  com- 
paratively thin,  and  is  mainly 
derived  from  the  internal 
longitudinal  layer  in  the  wall 
of  the  tube.  The  fibres  are 
arranged  circularly  round  the 
axis  of  the  uterus  at  its  centre 
and  lower  part,  and  at  the 
upper  part  circularly  round 
the  orifices  of  the  Falloj)ian 
tubes.  According  to  William  Hunter,  even  the  internal  coat  loses 
its  regularity  at  the  placental  site,  and  the  fibres  are  there  inter- 
laced irregularly  around  the  vessels,  the  effect  of  which  arrange- 
ment in  the  arrest  of  haemorrhage  is  obvious.  A  strong  circular 
band  of  fibres  surrounds  the  internal  os  uteri,  and  forms  a  true 
sphincter  to  the  uterine  cavity,  being  much  stronger  and  more 
ready  to  contract  than  any  other  part  of  the  circular  fibres 
(Fig.  107).  This  sphincter  muscle  is  more  manifest  clinically 
than  it  is  on  dissection.  In  the  unimpregnated  uterus  it  often 
leaves  its  impression  as  a  tight  constriction  round  a  laminaria  tent 
used  for  dilatation  ;  throughout  pregnancy,  according  to  the  modern 
doctrine,  it  holds  its  ground,  and  remains  closed  for  the  most  part, 
though  it  may  dilate  enough  to  admit  the  tip  of  the  finger  in  the 
last  month  or  two.  Even  in  labour  it  may  show  undue  spasmodic 
rigidity,  when  it  ought  to  relax.      After  delivery  it  is  the  first  part 


Fig.  107. — Diagram  of  internal  layer  of 
muscle  fibres  of  pregnant  uterus. 


Changes   in  the  Maternal   Organism.       149 

to  close,  while  the  cervix  still  remains  quite  thin  and  flaccid,  and 
may  enclose  thereby  a  retained  placenta. 

Uterine  Vessels. — The  main  arteries  supplying  the  uterus 
become  greatly  enlarged,  and  so  also  do  those  in  the  uterine  walls, 
especially  at  the  placental  site.  The  coats  of  the  arteries  are 
hypertrophied  and  thickened,  and  a  considerable  remnant  of  such 
thickening  appears  to  remain  even  after  involution,  and  to  furnish 


Fig.  108. — Arteries  and  veins lof  uterus.     (After  Heitzmann  and  Hyratl.) 

a  character  distinguishing  the  parous  from  the  nulliparous  uterus. 
The  arteries  ramifying  in  the  uterine  walls  anastomose  freely  with 
each  other.  As  they  penetrate  deeper  into  the  walls  and  approach 
the  internal  surface,  they  take  a  spiral  or  corkscrew-like  course 
(arteriffi  helicinse).  This  is  especially  marked  in  the  arteries  which 
convey  blood  into  the  placenta,  and  it  has  the  effect  of  facilitating 
the  closure  of  the  canals  by  the  contraction  of  the  uterine  muscular 
filn-es.  (See  Fig.  78,  p.  103.)  The  veins  are  still  more  enlarged, 
and  become  dilated  into  a  system  of  sinuses  communicating  with 
each  other,  chiefly  towards  the  internal  surface  of  the  uterus,^and 


150  The  Practice  of   Midwifery. 

more  especially  under  the  placental  site  (Figs.  78,  p.  103;  79,  p.  104). 
Some  of  these  may  be  large  enough  to  admit  the  tip  of  the  finger. 
The  veins  have  no  valves,  and  their  walls  are  not  separable  from 
the  uterine  tissue  (Fig.  108).  Their  course  is  generally  parallel  to 
the  surface,  and  is  occasionally  bent  back  suddenly  upon  itself, 
producing  what  has  been  called  a  "falciform  valve."  This  arrange- 
ment allows  the  vessel  to  be  closed  by  uterine  contraction.  In  the 
absence  of  uterine  contraction,  it  is  obvious  that  haemorrhage  may 
take  place  from  the  veins  as  well  as  from  the  arteries,  to  a  very 
considerable  amount. 

Uterine  Lymphatics  and  Nerves. — The  abundant  lymphatics 
of  the  uterus  form  plexuses  of  lymjDh-spaces  around  the  glands  and 
vessels  of  the  mucous  membrane,  and  beneath  the  serous  covering 
of  the  organ  these  open  into  collecting  branches  at  the  sides  of  the 
uterus,  which  in  their  turn  open  into  larger  trunks  in  the  broad 
ligaments. 

This  lymphatic  system  undergoes  great  enlargement  in  preg- 
nancy, and  fulfils  an  imj)ortant  function  both  in  the  tissue  changes 
attendant  upon  the  rapid  growth  of  the  uterus,  and  still  more  in  its 
rapid  involution  after  delivery.  The  great  development  of  lym- 
phatics also  accounts  for  the  proneness  to  absorption  of  septic 
matter  which  exists  after  delivery.^  A  great  controversy  formerly 
took  place  as  to  whether  or  not  the  nerves  of  the  uterus  grew  during 
pregnancy.  It  is  now  established  that,  as  might  be  expected,  growth 
does  take  place  in  the  nerves,  including  the  so-called  "  ganglion 
cervicale  uteri,"  which  increases  in  size  from  f  inch  to  2  inches  and 
I  inch  to  1^  inches,  to  fit  the  uterus  for  the  process  of  labour,  in  which 
both  reflex  action  and  periodic  centric  discharge  of  nervous  energy 
play  important  parts.  Even  during  pregnancy,  the  irritability  of 
the  uterus  is  considerably  increased.  Uterine  contractions,  gene- 
rally painless,  are  readily  excited  by  stimulus,  and  such  contractions 
take  place  at  intervals  even  without  any  stimulus.  The  contrac- 
tions are  of  service  in  promoting  the  circulation  through  the  uterine 
walls  by  emptying  from  time  to  time  the  large  venous  sinuses. 
Their  importance  as  regards  the  diagnosis  of  pregnancy  will  be 
further  explained  hereafter. 

Size  of  the  Uterus  in  the  successive  months  of  Pregnancy. — 
In  the  first  three  months  the  body  of  the  uterus  grows  more  in  its 

1  It  is  maintained  by  Hoggan  (Trans.  Obst.  Soc.  London,  1883,  Vol.  XXIII.,  p.  4)  that 
the  usual  account  of  the  lymphatics  of  the  iiterus  is  erroneous,  that  there  are  no  true 
subserous  lymphatics,  and  that  the  method  of  injection,  by  which  such  a  system  is 
supposed  to  be  demonstrated,  is  fallacious.  He  describes  only  a  deep  and  superficial 
layer  of  lymphatics  in  the  mucous  membrane,  and  muscular  lymphatics,  which 
occasionally  appear  under  the  serous  surface. 


Changes  in  the  Maternal   Organism.        151 

breadth  and  depth  than  in  its  length,  and  very  often  at  the  site  of  the 
insertion  of  the  ovum  there  is  a  definite  bulging  of  the  uterine  wall 
which  renders  the  outline  of  the  uterus  irregular  in  shape.  Hence 
the  pyriform  shape  of  the  organ,  though  maintained  to  some  extent 
throughout  the  first  three  months,  is  gradually  lost  (Fig.  121,  p.  177). 
By  the  end  of  the  third  month  the  whole  uterus  has  again  become 


Fig.  109. — Sagittal  section  of  gravid  uterus  of  fourth  month.    (Waldeyer,  Das 
Becken,  Fig.  96.) 

globular,  the  growth  of  the  body  being  very  marked  as  compared 
with  that  of  the  cervix,  and  it  retains  this  globular  or  egg-shaped 
form  up  to  the  sixth  month.  From  the  sixth  month  onwards, 
the  foetus  in  its  usual  attitude  begins  to  be  accommodated  to 
the  shape  of  the  uterus,  instead  of  floating  in  any  position,  and 
to  correspond  with  this  necessity,  the  growth  of  the  long  diameter 
of  the  uterus  again  predominates,  and  the  organ  again  acquires  a 
pear-shaped  form,  the  lower  segment  generally  containing  the  foetal 


152 


The   Practice  of   Midwifery. 


head.  In  abnormal  presentations  of  the  foetus  and  deformities  of 
the  spine  or  pelvis,  the  shape  of  the  uterus  may  be  considerably 
modified.  In  the  first  three  or  four  months,  the  weight  of  the 
fundus  causes  an  increase  of  the  normal  slight  anteversion  and 
anteflexion  of  the  unimpregnated  uterus.  At  the  eighth  week  the 
uterus  is  usually  about  the  size  of  a  goose's  egg.     At  the  twelfth 


Ob 
Internutn 


Utero -vesical 
pouch 


Fig.  110. — Sagittal  section  of  pregnant  uterus  at  eighteenth  week.     From 
frozen  section.     (Webster.) 

week,  or  the  end  of  the  third  lunar  month,  it  is  the  size  of  a  foetal 
head,  and  the  highest  point  of  the  fundus  reaches  about  6  cm. 
above  the  symphysis  pubis.  At  the  sixteenth  week,  or  the  end  of 
the  fourth  month,  the  uterus  usually  first  comes  into  contact  with 
the  abdominal  walls,  and  is  readily  detected  on  external  examination 
of  the  abdomen,  although  its  increased  size  may  be  detected  on 
bimanual  examination  at  a  very  early  stage,  even  as  early  as  the 
sixth  to  eighth  week.  Its  upper  limit  now  reaches  about  9  cm., 
one  hand's  breadth,  or  rather  more,  above  the  symphysis  pubis. 


Changes   in   the    Maternal  Organism.       153 

At  the  end  of  the  fifth  month  the  fundus  reaches  to  just  below  the 
umbilicus,  and  at  the  end  of  the  sixth  month,  or  the  twenty-fourth 
week,  it  is  a  little  above  the  umbilicus,  at  the  seventh  month,  or  the 
twenty-eighth  week,  two  to  three  fingers'  breadth  above  that  point, 
and  at  the  end  of  the  eighth  month,  or  the  thirty-second  week, 
about  two-thirds  of  the  distance  between  the  umbilicus  and  the 
ensiform  process.  At  this  period  the  greatest  circumference  of  the 
abdomen  is  approximately  97  cm.     At  the  thirty- sixth  week,  or 


TT' 


Fig.  111.— Diagram  of  the  level  of  the  fundus  uteri  at  the  different  weeks  of 

pregnancy. 


the  termination  of  the  ninth  month,  the  fundus  of  the  uterus 
reaches  its  highest  point,  namely,  the  line  of  the  ensiform 
cartilage,  and  the  circumference  of  the  abdomen  is  now  about 
99  cm.  At  full  term  the  uterus  has  sunk  a  little  downwards  and 
forwards,  and  its  highest  point  is  at  about  the  same  level  as  at  the 
thirty-sixth  week,  while  the  greatest  circumference  of  the  abdomen 
now  measures  on  an  average  100  cm.  This  descent  of  the  level  of 
the  fundus  is  due  to  the  sinking  of  the  whole  uterus  more  deeply 
into  the  pelvis,  which  occurs  normally  during  the  last  two  weeks  of 
pregnancy  (Fig.  111). 

It  is  obvious  that  the  level    of    the   fundus  will  tend  to  vary 


154 


The  Practice  of  Midwifery. 


somewhat  with  the  size  of  the  child,   the   presence   of   multiple 
pregnancies,  and  the  degree  of  laxness  of  the  abdominal  walls. 

Owing  to  the  pelvic  inclination,  the  pregnant  uterus  in  the  later 
months,  when  the  woman  is  standing  upright,  rests  upon  the 
anterior  abdominal  wall  as  an  inclined  plane,  its  axis  being  nearly 


Fig.  112. — Sagittal  section  of  uterus  and  child  at  end  of  pregnancy.  First 
stage  in  progress  slight  dilatation  of  internal  os  is  present.  Patient  died 
of  eclampsia.     (Leopold,  Altas  Uterus  und  Kind,  Plate  XIX.) 


coincident  with  the  axis  of  the  pelvic  brim,  and  the  abdominal 
wall  supports  a  greater  share  of  its  weight  than  the  pelvis.  "When 
the  woman  lies  on  her  back  the  uterus  falls  backward  against  the 
vertebral  column,  and  its  axis  is  inclined  posteriorly  to  the  axis 
of  the  pelvic  brim.  (See  Fig.  131,  p.  220,  and  Fig.  139,  p.  232.)  The 
uterus  being  flaccid  in  the  absence  of  contractions,  its  shaj)e  is 
affected  by  gravity,  and   thus,  both    in   the    upright   and    dorsal 


Changes  in  the   Maternal   Organism.       155 

positions,  especially  in  the  latter,  it  becomes  spread  out  laterally, 
and  its  antero-posterior  diameter  is  diminished.  The  intestines  lie 
chiefly  behind  and  above  the  uterus,  but,  in  the  dorsal  position,  they 
come  further  down  in  front  over  its  upper  margin.  The  axis 
of  the  uterus  is  rarely  central,  and,  as  in  the  unimpregnated  state, 
it  is  more  frequently  inclined  toward  the  right  side.  This  inclina- 
tion appears  to  depend  partly  upon  congenital  tendency,  partly 
upon  the  presence  of  the  rectum  and  sigmoid  flexure  toward  the 
left  side,  and  partly  upon  gravity,  since  most  persons,  on  account 
of  the  weight  of  the  liver,  prefer  to  lie  more  frequently  on  the 
right  side.  The  projection  of  the  vertebral  column  in  the  middle 
line  increases  the  tendency  of  the  pregnant  uterus  to  fall  to  one 
side  or  other  in  the  dorsal  position.  In  addition  to  the  inclina- 
tion, there  is  in  about  80  per  cent,  of  all  cases  also  a  slight  rotation 
of  the  uterus  towards  the  right,  so  that  its  anterior  surface  looks 
not  directly  forward,  but  somewhat  to  the  right. 

Changes  in  the  Cervix  Uteri. — It  was  formerly  believed 
that,  during  the  later  months  of  pregnancy,  the  cervix  uteri  was 
gradually  spread  out  from  above  downward,  and  thus  formed  the 
lower  segment  of  the  pear-shaped  uterine  cavity.  It  is  now 
established  that  such  spreading  out  is  really  a  part  of  the  process 
of  labour,  and  that,  in  the  great  majority  of  cases,  it  does  not  take 
place  until  either  a  few  days  before  active  labour,  when  it  may  be 
effected  by  painless  uterine  contractions,  or,  more  frequently,  until 
the  commencement  of  definite  labour  pains.  In  very  exceptional 
cases,  however,  generally  those  of  primiparge,  the  cervix  may  be 
expanded,  so  that  the  bag  of  membranes  rests  upon  the  external 
OS,  for  some  weeks  before  actual  labour.  Much  more  frequently, 
especially  in  multiparee,  there  is  partial  dilatation  of  the  internal  os 
in  the  last  four  to  six  weeks  of  pregnancy,  sufiicient  to  let  the  finger 
pass  through  and  feel  the  foetus  presenting,  but  in  these  cases  the 
cervix  still  remains  a  separate  cavity,  unoccupied  by  the  bag  of 
membranes. 

The  Cervix  and  Lower  Uterine  Segment. — The  question  of 
the  exact  relationship  of  the  lower  uterine  segment  to  the  cervix  is 
one  which  has  excited  a  great  deal  of  controversy,  and  is  by  no 
means  settled  even  at  the  present  time.  There  are  three  main 
views  held  as  to  the  nature  and  mode  of  origin  of  the  lower  uterine 
segment.  The  first,  which  has  the  su[)port  of  Bandl,  Bayer,  and 
Kiistner,  is  that  the  upper  part  of  the  cervical  canal  becomes 
enormously  dilated  in  the  later  months  of  pregnancy,  and  forms. 


156 


The   Practice  of   Midwifery. 


together  with  a  part  of  the  body  of  the  uterus,  the  lower  uterine 
segment.  The  second  view,  which  is  supported  by  Bumm  and 
Blumreich,  is  that  there  is  no  lower  uterine  segment  at  all,  and  that 
the  part  of  the  uterus  which  has  been  described  as  such  is  in  reality 
the  greatly  thinned  and  distended  cervix.  The  third  view,  accepted 
amongst  others  by  Leopold,  Yon  Franque,  Waldeyer,  Yarnier,  and 
Barbour,  is  that  the  cervix  remains  undilated  up  to  the  commence- 
ment of  labour,  except  in  some  extremely  rare  cases,  that  it  takes 


ut  jS. 


_J r^ 


L if  -ut  J 


Fig.  11.3. — Diagram  of  uterus  showing  the  segments  and  the  ring  of  Bandl. 
u.  ut.  s.,  upper  uterine  segment ;  r.  B.,  ring  of  Bandl  ;  I.  ut.  s.,  lower 
uterine  segment ;  i.  o..  internal  os  ;  e.  o.,  external  os. 


no  part  in  the  formation  of  the  cavity  of  the  uterus,  and  no  part  in 
the  development  of  the  lower  uterine  segment,  and  that  the  latter  is 
formed  from  the  body  of  the  uterus  alone.  The  following  meaning 
of  the  terms  used  by  different  authors  must  be  clearly  understood. 
Miiller's  ring  is  the  upper  orifice  of  the  cervical  canal  in  the  later 
months  of  pregnancy,  and  is  usually  considered  as  identical  with 
the  internal  os.  By  Bandl's  ring  is  meant  a  projecting  ridge  felt 
during  labour  either  on  the  internal  surface  of  the  uterus  or 
through   the   abdomen   on   its   outer   surface   as   a   ridge   with   a 


Changes   in   the  Maternal   Organism.       157 

depression  below  it,  and  situated  at  a  varying  distance  above  the 
symphysis  pubis.  According  to  those  who  support  the  view  of 
Bandl  as  to  the  origin  of  the  lower  uterine  segment,  and  by  Bumm 
and  Blumreich,  the  ring  of  Bandl  is  held  to  be  situated  at  the  level 
of  the  internal  os.  If,  on  the  other  hand,  we  accept  the  third  view, 
that  the  cervix  takes  no  part  at  all  in  the  formation  of  the  lower 
uterine  segment,  then  the  ring  of  Bandl  represents  the  line  of 
union  between  the  thickened  contractile  portion  of  the  body  of  the 
uterus,  or  the  upper  segment,  and  the  thinned  distensile  portion  of 
the  uterus,  or  the  lower  segment,  and  on  this  view  of  its  nature  it 
has  also  been  termed  the  retraction  or  contraction  rincr. 

O 

It  would  seem  at  first  sight  as  if  there  should  not  be  any 
difficulty  in  determining  by  the  examination  of  microscopical 
sections  whether  the  lower  segment  is  derived  from  the  body  of  the 
uterus  or  from  the  cervix.  Unfortunately  in  many  instances  this  is 
impossible,  owing  to  the  bad  state  of  preservation  of  the  tissues. 

Further,  there  is  some  difficulty  in  deciding  whether  the  internal  os 
should  be  defined  as  the  point  where  the  mucous  membrane  changes 
its  character,  or  as  that  where  the  strongest  ring  of  sphincter  muscle 
is  situated.  The  latter  definition  appears  preferable,  since  it  is  the 
only  one  applicable  to  the  infantile  uterus,  in  which  the  arbor  vitaB 
of  the  cervical  mucous  membrane  extends  some  way  into  the  body 
of  the  uterus.  Adopting  this  definition,  the  evidence  greatly 
preponderates  that,  setting  aside  the  very  exceptional  cases  of 
primiparse  noted  above,  the  upper  limit  of  the  cervical  canal  in  the 
later  months  of  pregnancy  is  the  true  clinical  internal  os,  possessing 
its  powerful  ring  of  sphincter  muscle,  although  it  may  be  true  that 
the  characters  of  cervical  mucous  membrane  may  occasionally 
extend  higher  up,  or,  as  Kiistner  has  shown,  the  formation  of 
decidua  may  extend  some  distance  down  the  cervix. 

If  an  examination  be  made  at  the  first  onset  of  hemorrhage  in 
the  case  of  a  placenta  preevia,  it  may  often  be  observed  that  the 
upper  orifice  of  the  cervical  canal  is  as  yet  but  slightly  dilated,  and 
that  the  placenta  is,  in  some  places,  attached  to  the  lower  portion 
of  the  uterine  body  up  to  the  very  edge  of  the  orifice.  This  con- 
dition is  seen  in  the  frozen  section  of  placenta  praevia  (Chap.  XXY.). 
Specimens  have  also  been  described,  notably  by  Matthews  Duncan, 
Angus  Macdonald,  and  Miiller,  in  which,  at  the  end  of  pregnancy, 
the  membranes  were  found  attached  down  to  the  very  edge  of  the 
same  orifice,  at  which  orifice  also  the  cervical  mucous  membrane 
apj)eared  to  begin. 

Bandl  detected  characters  of  cervical  mucous  membrane  above 
the  limit  of  the  apparent  internal  os,  which  closes  the   cervical 


158  The   Practice  of   Midwifery. 

canal  above  toward  the  end  of  pregnancy.  He  believed  that  in  the 
later  months  the  upper  part  of  the  cervical  canal  became  enor- 
mously dilated,  so  that  the  true  internal  os  lay  at  a  point  above  the 
symphysis  pubis,  and  concluded  that  the  muscular  ring  forming 
the  internal  os  was  gradually  shifted  upwards  during  the  last  few 
weeks  of  pregnancy  in  reference  to  the  limit  of  the  cervical  mucous 
membrane,  so  that  it  became  expanded  and  incorporated  with  the 
muscle  of  the  lower  uterine  segment.  In  this  way  he  accounted  for 
the  high  position  of  the  internal  os  in  Braune's  frozen  sections 
(Fig.  132,  p.  221),  Experience  shows  that,  if  a  woman  dies  during  or 
shortly  after  labour,  the  uterus  post  mortem  frequently  shows  no 
sharp  line  of  demarcation  between  the  thickened  and  the  thinned 
segment,  nor  any  projecting  ridge,  but  only  a  gradual  transition  ; 
and  thus  the  inward  projection  of  the  ring  is  mainly  a  clinical 
phenomenon,  dependent  upon  active  muscular  action. 

A  further  difficulty  is  introduced  by  the  moulding  of  the  uterus 
upon  the  foetus,  which  occurs  during  the  second  stage  of  labour, 
and  which  leads  to  the  formation  of  projections  on  the  inner  surface 
of  the  uterus  which  have  in  some  instances  been  wrongly  interpreted 
as  the  ring  of  Bandl.  The  preponderance  of  evidence  appears  to 
be  in  favour  of  the  view  that  the  lower  uterine  segment  is  formed 
wholly  from  the  body  of  the  uterus,  and  it  may  be  defined  as  that 
part  of  the  uterus  which  must  be  converted  into  a  canal  so  as  to 
allow  the  foetus  to  pass.  It  forms  rather  less  than  a  fourth  of  the 
total  cavity  of  the  uterus,  and,  owing  to  its  distension,  its  muscle 
contracts  less  efficiently  than  that  of  the  rest  of  the  uterus  during 
labour.  As  a  general  rule  it  further  represents  that  part  of  the 
uterine  wall  from  which  the  membranes  are  stripped  off  in  the 
formation  of  the  bag  of  membranes  (Barbour).  The  retraction  ring, 
or  the  ring  of  Bandl,  forms  the  lower  boundary  of  the  retracted 
area  of  the  uterine  musculature.  Whether  the  retraction  ring 
forms  at  the  internal  os,  as  it  may  do  in  some  rare  cases,  or  higher 
up,  as  is  usually  the  case,  will  depend  upon  the  contractile  efficiency 
of  the  uterine  muscle.^ 

Softening. — From  the  commencement  of  pregnancy,  a  softening 
begins  in  the  texture  of  the  cervix,  owing  to  congestion  and  the 
effusion  of  serum  in  its  substance.  As  early  as  the  end  of  the 
first  month,  a  softening  of  the  superficial  tissue  just  at  the  tip  of 

1  Eeference  may  be  made  to  the  following  papers  : — Duncan,  Researches  in  Obstetrics, 
pp.  243—273  ;  Macdonald,  Edin.  Med.  Journ.,  April,  1877  ;  Bandl,  Ueber  das  Verbal  ten 
des  Uterus  und  Cervix  in  der  Schvvangerschaft,  Stuttgart,  1876  ;  also  Archiv  fiir 
Gynak.,  XII.,  p.  334  ;  Kustner,  Ibid.,  XII.,  p.  303  ;  Miiller,  Ibid.,  XIII.,  p.  150,  and 
XIV.,  p.  184  ;  Sanger,  Ihid.,  p.  389  ;  Hart,  Atlas  of  Female  Pelvic  Anatomy,  pp.  63 — • 
77  ;  Barbour,  Brit.  Med.  Journ.,  1890,  p.  1002,  and  "  Atlas  on  the  Anatomy  of  Labour 
as    exhibited  in  Frozen   Sections,"  3rd  ed.,  1896  ;     Dittel,    Diel  Dehuungszone   des 


Changes   in   the   Maternal   Organism.       159 


the  cervix  may  be  detected.  From  this  part  the  softening  spreads 
both  more  deeply  into  the  tissue  and  upwards  towards  the  uterus. 
Towards  the  end  of  pregnancy  the  softening  is  sometimes  so 
extreme,  that  an  inexperienced  person  may  find  it  difficult  to 
distinguish  the  cervix  from  the  vagina.  By  the  fourth  month 
the  softening  is  generally  sufficiently  advanced  to  be  characteristic, 
although  in  some  cases  of  multiparas,  where  there  has  been  a 
previous  induration  of  the  cervix,  the 
softening  is  much  later  in  making  itself 
manifest.  If,  however,  a  woman  is  sup- 
posed to  be  in  the  later  months  of 
pregnancy,  and  the  cervix  is  found  to  be 
unsoftened,  and  projecting  into  the 
vagina  as  in  the  unimpregnated  state, 
there  is  a  very  strong  presumption  that 
the  supposed  pregnancy  does  not  exist, 
or  is  not  intra-uterine.  On  the  other 
hand,  very  marked  softening  may  exist 
without  any  pregnancy,  as  in  some 
exceptional  cases  of  fibroid  tumours. 
The  absence  of  softening  is  thus  of  more 
decisive  value  as  a  negative,  than  its 
presence  as  a  positive  sign. 

Apparent  Shortening.  ■ —  Besides  this 
softening,  there  is  an  apparent  shorten- 
ing of  the  cervix,  as  felt  on  vaginal 
examination,  and  it  was  upon  this 
shortening  that  the  old  theory  about  the 
cervical  cavity  being  taken  up  into  that 
of  the  uterus  was  largely  based.  If, 
however,  an  opportunity  occurs  of  ex- 
amining the  length  of  the  cervical  canal, 
either  after  death,  or  from  the  external 
OS  being  patulous  enough  to  allow  the 
finger  to  be  passed  into  it,  it  is  almost  always  found  that  the 
canal  is  lengthened  rather  than  shortened,  as  compared  with  that 
of  the  unimpregnated  uterus,  its  average  length  being  3*5  cm. 
The  apparent  shortening  depends  upon  two  causes.     The  first  is 

Schwangeren  und  Kreissenden  Uterus,  Leipzic,  1898  ;  Von  Franque,  Cervix  und 
unteres  Uterinsegnient,  Stuttgart,  1897;  Untersuchungen  und  Erorterungen  zur 
Cervixfrage,  Wilrzburg,  1899  ;  H.  Bayer,  "  Morphologie  der  Gebarmutter,"  Freund, 
Gynakologische  Klinik,  Strassburg,  1885  ;  G.  Leopold  Atlas  Uterus  und  Kind,  Leipzic, 
1897  ;  W.  Waldeyer,  Medianschritt  einen  Hochschwangeren,  Bonn,  1866  ;  A  Pinard 
and  A.  Varnier,  Sltudes  d'Anatomie  Obstetrical,  Paris,  1892  ;  Bumm  and  Blumreich, 
Zeitsch.  f.  Geb.  u.  Gyn.    B.  58,  1906. 


Fig.  114. — Diagram  to  illus- 
trate how  there  may  be 
apparent  shortening  of  the 
cervix,  as  seen  and  felt 
from  the  vagina,  without 
any  shortening  of  the  cer- 
vical canal.  The  upper 
figure,  A,  shows  the  cervix 
at  about  the  third  month, 
the  lower,  b,  at  about  the 
eighth  month  of  pregnancy, 
u,  cavity  of  uterus ;  V, 
vagina  ;  B,  bladder. 


i6o 


The   Practice  of   Midwifery. 


the  thickening  and  extension  of  the  uterine  wall,  coupled 
with  the  loosening  of  the  vaginal  tissue  adjoining,  and  a  traction 
upwards  exercised  by  the  enlarging  uterus  upon  the  cervix  as  it 
rises  higher  into  the  abdomen.  In  consequence  of  this,  the  pro- 
jection of  the  lip  of  the  cervix  into  the  vagina  may  become  less, 
without  any  diminution  of  its  distance  from  the  cavity  of  the  uterus 
(see  Fig.  114).  This  is  especially  marked  as  regards  the  anterior  lip 
of  the  cervix,  because  the  prominence  of  the  uterine  wall  in  front, 
due  to  its  expansion,  is  generally  increased  by  a  bulging  outward, 
due  to  the  pressure  of  the  foetal  head  resting  in  that  situation,  and 
thus  the  angle  between  the  anterior  lip  and  the  vaginal  wall  tends 


Fig.  115. — Condition  of  the  cervix  with  the  head  above  the  pelvic  brim  at  the 
seventh  month  of  pregnancy.     (Bumm. ) 


to  become  effaced.  The  second  cause  is  the  alteration  in  the  direc- 
tion of  the  cervical  canal.  This  is  generally  somewhat  flexed 
forward,  even  in  the  unimpregnated  uterus.  As  pregnancy  advances, 
it  generally  becomes  more  and  more  inclined  forward  in  reference 
to  the  axis  of  the  uterus,  so  that  the  two  meet  at  an  angle  at  the 
internal  os(Fig.  114).  By  this  means,  the  lips  of  the  cervix  may 
become  approximated  to  the  uterine  cavity,  although  the  length  of  the 
cervical  canal  is  actually  being  increased,  as  shown  in  Fig.  116. 
Towards  the  end  of  pregnancy,  the  cervix  uteri  becomes  more 
difficult  to  reach,  since  it  is  drawn  upward  by  the  uterus  rising 
into  the  abdomen,  and  frequently,  in  addition,  is  tilted  backward 
toward  the  sacrum,  in  consequence  of  the  fundus  falling  forward 
through  its  own  weight. 


Changes   in  the   Maternal   Organism.       i6i 

The  cervical  glands  secrete  a  thicker  mucus  than  usual  during 
pregnancy,  and  this  usually  forms  a  tenacious  white  mucous  plug, 
filling  up  the  cervical  canal.  In  parous  women,  if  there  is  a 
previously  existing  eversion  of  the  mucous  membrane  from  lacera- 
tion of  the  cervix  in  a  former  labour,  giving  the  appearance  of  a 
so-called  erosion,  the  hyperfcrophied  papillae,  or  villous  prominences, 
become  much  more  enlarged,  florid,  and  soft.  The  external  os 
generally  becomes  more  patulous  than  in  the  unimpregnated  state, 
but  this  change  is  more  marked  in  multiparse,  in  whom  the  os 
is  wider  to  begin  with.     In  first  pregnancies  the  os  is  generally 


Fig.  116. — Head  engaged  in  the  pelvic  brim  at  full  term,  showing  the  apparent 
shortening  of  the  cervix  and  obliteration  of  the  anterior  vaginal  fornix. 
(Bumm.) 


closed  to  the  finger  up  to  nearly  the  end  of  pregnancy  (Fig.  116). 
In  multiparse  the  finger  may  generally  be  passed  into  the  cervix 
in  the  later  months,  if  not  through  the  internal  os. 


Changes  in  Vagina  and  other  adjacent  Parts.  The  mucous 
membrane  and  muscular  walls  of  the  vagina  become  hypertrophied, 
and  its  secretion  increased.  From  about  the  third  to  the  fourth 
month  the  anterior  vaginal  wall  feels  stretched,  from  the  commenc- 
ing ascent  of  the  uterus,  as  well  as  turgid.  In  the  later  months 
there  is  so  much  hypertrophy  and  relaxation  of  the  mucous 
membrane  that,  notwithstanding  the  lengthening  of  the  vagina,  it 
tends  to  hang  in  folds,  which  appear  at  the  vulva,  the  prominence 
covering  the  urethra  being  often  especially  marked.     The  mucous 

M.  11 


1 62  The   Practice  of   Midwifery. 

membrane   of    the   vulva   also  becomes   turgid   and   relaxed,    the 
secretion  of  the  follicles  increased,  the  veins  enlarged,  and  often 
varicose,    the   vaginal  outlet  wider.     The  projection  of  the  pelvic 
floor  beyond  the  outlet   of   the   bony   pelvis  is,   in   consequence, 
notably   increased.     The  round  ligaments  are  much  increased  in 
thickness  as  well  as  in  length,  in  consequence  of   the  hypertrophy 
of  the  muscular  fibres  contained  in  them.     Owing  to  the  elevation 
of  the  fundus  they  become  inclined  at  a  much  greater  angle  to  the 
pelvic  brim  than  in  the  unimpregnated  state.     Their  action  is  to 
draw  the  fundus  downwards  and  forwards  in  reference  to  the  axis 
of  the  brim.     According  to  Leopold,  when  the  points  of  insertion  of 
the  round  and  ovarian  ligaments  are  relatively  close  together  and 
on    the    anterior    wall    of    the   uterus    the    placenta  is  probably 
situated  on  the  posterior  wall,  while  when  they  are  farther  apart 
and  on  the  lateral  aspects  of  the  uterus  the  placenta  is  most  likely 
to  be  situated  on  the  anterior  wall.      The   broad   ligaments   grow, 
rather  than  become  unfolded,   and   the   direction   of   their   ujDper 
margins  becomes  very  oblique.     Owing  to  the  expansion  upwards 
of  the  fundus  uteri,  the  insertion  of  the  round   and  ovarian  liga- 
ments is  no  longer  nearly  at  the  level  of  the  summit  of  the  uterus, 
but  toward  the  lower  part  of  its  upper  third.     The  Fallopian  tubes 
are  increased  in  length  and  diameter,  and  their  direction  becomes 
nearly   perpendicular  to  the   pelvic   brim.       The   position    of   the 
ovaries,  which  also  share  in  the  general  hypertrophy  of  the  pelvic 
organs,  thus  comes  to  be  comparatively  low  down  in  reference  to 
the  body  of  the  uterus,  and  near  to  its  walls.       The   formation   of 
the  corpus  luteum  in  the  ovary  has  been  described  already  (p.  55). 
Further  maturation  of  follicles  is  almost  invariably  arrested  during 
pregnancy,  but  this  question  will  be  further  discussed  under  the 
head   of  superfoetation.     Whether   ovulation    accompanies    or   not 
the  menstruation   which  sometimes   occurs   during   the   first   few 
months  of  pregnancy,  has  not  been  demonstrated.     Probably  in  all 
cases  of  normal  pregnancy  there  is  an  over-production  of  lutein 
cells   in   the   ovary   and   a   formation   of    atretic   follicles.        The 
whole  cellular  tissue  of   the  pelvis  partakes  in  the   same   growth 
and  relaxation  as  the  broad  ligaments,  and  the  nutritive  changes 
affect  even  the  pelvic  joints,  as  already   described    (see    p.    12) ; 
increased  deposit  of  external  fat  also  takes  place  about  the  pelvis 
and  loins. 

Mechanical  Effects  on  other  Parts. — Mechanical  effects  arise 
partly  from  the  direct  pressure  of  the  enlarged  uterus,  partly  from 
the    increased   intra-abdominal    pressure  caused  by  its  presence. 


Changes   in   the  Maternal   Organism.       163 

The  degree  of  the  latter  depends  upon  the  tightness  of  the 
abdominal  walls,  which  is  generally  much  greater  in  first  preg- 
nancies. The  capacity  of  the  bladder  is  diminished,  chiefly  by 
direct  pressure  of  the  uteras.  Hence  there  is  a  more  frequent  need 
for  micturition ;  and  sometimes,  in  addition,  urine  is  involuntarily 
expelled,  especially  in  the  upright  position.  Constipation  is  often 
troublesome,  and  is  to  be  ascribed  not  so  much  to  direct  i3res8ure 
upon  the  rectum  as  to  general  interference  with  the  freedom  of 
peristaltic  movement  of  intestines.  Sometimes  the  pressure  on  the 
veins  causes  oedema  of  the  feet  and  legs,  and  in  some  cases  also  of 
the  vulva ;  but  this  oedema  is  not  often  considerable  in  degree 
unless  there  is  some  additional  cause,  such  as  disorder  of  the 
kidneys.  When  there  is  any  tendency  to  imperfection  of  venous 
circulation,  the  veins  of  the  lower  extremities  and  vulva  often 
become  varicose,  and  this  varicosity  may  become  very  severe  in 
degree.  It  is  relieved,  to  a  great  extent,  by  a  recumbent  posture. 
In  the  abdominal  walls  a  certain  amount  of  growth  and  relaxation 
as  well  as  stretching  occurs.  The  umbilical  depression  becomes 
gradually  obliterated,  is  flat  with  the  surface  of  the  abdomen 
usually  at  the  end  of  the  seventh  month,  and  in  the  last  months 
generally  forms  a  soft  prominence.  In  women  whose  tissues  are 
wanting  in  tone,  the  recti  are  sometimes  separated  from  each  other 
in  their  middle  and  upper  thirds — a  condition  which  may  remain 
permanent  after  delivery. 

From  the  end  of  the  fifth  month  of  pregnancy  skin -cracks,  or 
cutaneous  strice,  are  generally  formed  from  the  effect  of  tension. 
They  are  caused  by  a  more  or  less  complete  disruption  of  the  deeper 
connective  tissue  layer,  especially  of  the  elastic  fibres  of  the  skin, 
and  therefore  run  at  right  angles  to  the  direction  of  greatest  tension. 
They  are  chiefly  seen  at  the  sides  of  the  abdomen  towards  the  lower 
part,  running  parallel  to  Poupart's  ligament  or  to  the  linea  alba,  or 
tending  to  curve  round  the  umbilicus.  They  may  be  formed  also 
upon  the  breasts,  buttocks,  and  thighs.  Schultze  found  them  on  the 
thighs  in  36  per  cent,  of  all  multiparse  examined  and  in  6  per  cent, 
of  men.  Although  they  have  been  called  lince  gravidarum,  they  are 
not  peculiar  to  pregnancy,  but  may  occur  from  any  kind  of  disten- 
sion, even  from  the  rapid  growth  of  fat.  In  only  twenty-eight  of 
492  cases  of  pregnancy  observed  by  Hecker  were  they  absent. 
They  have  the  appearance  of  short  spindle-shaped  lines,  generally 
about  half  an  inch  to  an  inch  in  length.  While  the  tension  lasts, 
they  are  reddish  or  bluish  ;  after  delivery  they  remain  as  opaque 
white  lines.  Sometimes  they  become  the  special  seat  of  cedema, 
or  of  distension  of  lymphatics,  in  consequence  of  the  diminution 

11—2 


164 


The   Practice  of   Midwifery. 


over  their  area  of  the  uniform  support  afforded  by  the  elasticity 
of  the  skin.^ 

Changes  in  the  Breasts. — Almost  from  the  very  outset  of  preg- 
nancy there  may  be  a  sense  of  fulness  and  tenderness  in  the 
breasts,  sometimes  with  darting  pains  referred  to  the  nipples  or 
glands.  These  may  be  regarded  as  the  continuation  and  develop- 
ment of  the  similar  symptoms  sometimes  felt  by  sensitive  women 
before  the  onset  of  menstruation.  By  the  second  month  actual 
enlargement  of  the  breasts  may  become  noticeable,  and  it  grows 


Fig.  ]17. — Mammary  changes  in  later  months  of  pregnancy, 
with  secondary  areola. 

gradually  more  manifest  as  pregnancy  advances.  The  enlargement 
is  mainly  in  the  glandular  tissue  itself,  though  the  connective  tissue 
and  fat  also  take  part  in  it.  Hence  the  breast  has  a  knotty  feel, 
due  to  irregular  thickenings  in  the  gland  tissue  radiating  from  the 
nipple.  In  the  later  months  enlarged  blue  veins  may  be  seen  under 
the  surface  of  the  skin.  In  an  enlargement  due  to  fat  there  is  not 
the  same  knotty  feel,  and  the  vascular  supply  is  not  altered. 

More  characteristic  signs  are  found  in  the  nipples  and  areolae. 
The  nipples,  unless  when  flattened  through  pressure  by  the  stays, 
become  more  prominent  and  more  susceptible  to  erection.  They 
are  often  covered  with  minute  branny  scales,  due  to  the  drying  of 

1  See  Busey,  "The  Cicatrices  of  Pregnancy,"  Trans.  Am.  Gyntec.  Soc,  Vol.  IV.; 
"Duncan,  "Phlegmasia  Dolens  with  Lymphatic  Varix,"  Trans.  Obst.  Soc.  London, 
1881,  Vol.  XXIII.,  p.  132. 


Changes   in   the   Maternal   Organism.       165 

the  small  quantity  of  secretion  which  oozes  from  them.  The 
areolae  become  enlarged  and  darkened  by  pigment.  This  change, 
however,  varies  very  greatly  according  to  the  complexion  of  the 
woman.  In  dark  brunettes  the  areolae  may  become  almost  black, 
in  blondes  the  deposit  of  pigment  may  be  hardly  noticeable.  The 
glandular  tubercles  of  the  areola  (Montgomery's  glands),  resembling 
miniature  nipples,  ten  to  twenty  in  number,  become  enlarged  and 
prominent,  and  the  whole  areola  moist,  and  slightly  elevated  above 
the  skin.  The  tubercles  may  have  an  excretory  duct  from  which 
a  little  milky  or  mucoid  fluid  exudes.  In  the  later  months  there 
is  developed  in  dark  women  around  the  outer  part  of  the  areola 
what  was  described  by  Montgomery  as  the  secondary  areola.  The 
appearance  is  that  of  white  spots  on  a  darker  ground,  and  is  usually 
compared  to  that  of  colour  discharged  by  a  shower  of  drops  of 
water  falling  on  a  tinted  ground.  The  secondary  areola  may  begin 
to  be  visible  in  some  cases  as  early  as  the  fifth  month,  and  its 
presence  affords  a  strong  presumption  of  pregnancy  (see  Fig.  117). 
Towards  the  end  of  pregnancy  the  breasts  droop  somewhat,  and  the 
nipples  become  directed  downward,  so  as  to  be  better  adapted  for 
the  infant  to  seize. 

It  is  possible  in  many  cases  as  early  as  the  third  month  to 
squeeze  a  drop  of  secretion  from  the  breasts  by  dexterously  com- 
pressing them  from  the  base  toward  the  nipple.  As  pregnancy 
advances  this  becomes  increasingly  easy.  The  product  formed  by 
the  mammary  gland  at  this  stage  of  its  evolution  is  not  milk,  but 
a  mucoid  fluid,^  and  accordingly  the  drop  so  squeezed  out  is  quite 
clear  and  transparent.  Later  on  in  pregnancy  some  opaque  white 
material  is  generally  seen,  mixed  with  the  clear  mucoid  fluid.  On 
microscopic  examination  this  is  found  to  consist  of  the  so-called 
"  colostrum  corpuscles,"  similar  to  those  found  in  the  first  secretion 
after  delivery.  While  mucoid  fluid  may  be  found  in  conditions  of 
irritation  of  uterus  or  ovaries,  or  in  spurious  pregnancy,  colostrum 
is  an  almost,  if  not  absolutely,  certain  proof  of  pregnancy,  uterine 
or  extra-uterine. 

Diagnostic  Value  of  Mammary  Changes. — Changes  in  the  breasts 
similar  to  the  early  stages  of  those  associated  with  pregnancy  not 
infrequently  occur  in  connection  with  various  uterine  and  ovarian 
tumours,  and  especially  with  the  so-called  "  pseudo-cyesis,"  or 
imaginary  pregnancy,  found  mostly  in  women  whose  menstruation 
is  becoming  irregular  with  the  approach  of  the  menopause. 
Mammary  changes  also  sometimes  occur  when  women  have  reason 
to'  expect  pregnancy,  as  shortly   after  marriage,    or   after   illicit 

'  See  Creightoii,  "  I'liysiology  and  Pathology  of  the  Breast,"  p.  49. 


1 66  The   Practice  of   Midwifery. 

intercourse.  After  a  previous  pregnancy  they  are  of  little 
diagnostic  value,  for  the  alteration  in  the  areolae  remains  in  some 
degree  permanent,  and  a  little  secretion  may  sometimes  be  still 
found  in  the  breasts  for  a  long  time  after  lactation  has  ceased,  or 
even  when  nothing  more  than  a  miscarriage  has  taken  place.  In 
the  case  of  a  young  woman  suspected  of  pregnancy,  the  examination 
of  the  breasts  is  of  very  great  though  not  of  decisive  value.  It  has 
the  special  advantage  that  it  may  often  be  more  readily  secured 
than  the  opportunity  for  vaginal  examination,  and  may  indicate  the 
necessity  for  further  investigation.  Some  excuse  may  be  found  to 
look  at  the  breasts,  even  if  we  wish  to  avoid  giving  any  hint  of  our 
suspicions  to  the  woman  herself.  In  the  absence  of  very  marked 
changes,  the  point  especially  to  be  sought  for  is  to  obtain  a  drop  of 
secretion,  since  this  sign  is  independent  of  varieties  of  complexion. 
It  is  a  sign  also  which  often  can  be  found  at  quite  an  early  stage, 
before  other  signs  exist,  except  such  as  may  be  overlooked  by  any 
but  a  practised  observer.  The  secondary  areola  is  strong  evidence 
when  it  is  visible,  but  it  does  not  appear  until  the  stage  when 
positive  proof  may  be  obtained  by  the  examination  and  auscultation 
of  the  uterus.  In  women  who  become  pregnant  again  while 
suckling  a  previous  child,  the  sign  of  pregnancy  is  to  be  found 
rather  in  suppression  of  the  milk  than  in  increased  mammary 
activity. 

Changes  in  the  BoD3fT?ENEKALLY. 

Circulation. — In  some  animals,  at  any  rate,  the  total  amount  of 
blood  in  the  body  during  pregnancy  is  increased,  and  it  may  be 
assumed  that  the  same  holds  good  for  the  human  female ;  and,  as 
it  is  not  found  that  the  pulse  is  more  rapid  in  pregnant  women,  the 
cavities  of  the  heart  must  be  dilated  so  as  to  propel  more  blood  at 
each  stroke,  if  the  circulation  is  to  be  as  active  as  before.  This  is 
found  actually  to  take  place.  With  the  dilatation  is  associated 
hypertrophy,  which  appears  to  be  not  merely  compensatory  to  the 
dilatation,  but  to  go  so  far  as  actually  to  improve  the  circulation. 
Thus  women  who  are  subject  to  chilblains  at  other  times  may  be 
exempt  from  them  during  pregnancy. 

The  increase  in  the  area  of  cardiac  dulness,  which  is  usually 
present,  and  which  might  be  assumed  to  prove  the  existence  of 
hypertrophy  of  the  heart,  is  in  reality  due  to  a  displacement 
upwards  of  the  organ  as  a  result  of  the  presence  of  the  pregnant 
uterus  in  the  abdomen.  A  good  deal  of  difference  of  opinion  still 
exists  as  to  whether  there  is  any  real  increase  in  the  size  of  the 
heart  during  pregnancy,  but  the  researches  of  Dreysel,  Miiller,  and 


Changes   in   the    Maternal   Organism.       167 

others,  appear  to  demonstrate  an  actual  increase  in  the  weight  of 
the  organ,  and  we  may  conchide,  therefore,  that  probably  both 
hypertrophy  and  dilatation  do  take  place.  In  women  in  a  normal 
state  of  health  the  changes  in  the  blood  are  unimportant.  The  red 
corpuscles  and  the  haemoglobin  remain  unaffected,  the  specific 
gravity  is  normal,  but  there  is  a  slight  diminution  in  the  alkalinity 
of  the  blood,  and  a  marked  degree  of  leucocytosis.  The  chief 
increase  is  in  the  polymorpho-nuclear  leucocytes.  According  to 
Zangemeister,  the  freezing  point  is  lowered,  and  the  albuminous 
content  is  diminished. 

The  frequent  cases  in  which  impoverishment  of  the  blood  is 
marked  must  be  regarded  as  deviations  from  health.  They  depend 
for  the  most  part  either  upon  the  impairment  of  digestion  which 
often  occurs,  or  upon  a  want  of  that  increased  supply  of  nourishing 
food  which  pregnancy  calls  for. 

In  these  cases  important  changes  take  place  in  the  quality  of 
the  blood.  It  becomes  richer  in  fibrin  and  in  white  corpuscles, 
poorer  in  red  corpuscles,  and  also,  especially  as  regards  the  liquor 
sanguinis,  in  albumen.  The  average  diminution  of  red  corpuscles 
is  about  11  per  cent. ;  the  average  diminution  of  haemoglobin 
somewhat  greater,  about  13  per  cent. 

Blood  Pressure. — The  blood  pressure  is  raised  during  pregnancy, 
and  most  observers  are  agreed  that  this  rise  occurs  mainly  during 
the  second  half  of  pregnancy,  and  that  there  is  little  or  no  alteration 
in  the  blood  pressure  during  the  early  months. 

The  pressure  is  at  its  highest  towards  the  end  of  gestation,  and 
during  the  second  stage  of  labour  there  is  a  further  marked  rise. 
Immediately  after  delivery  a  fall  occurs  to  below  the  normal,  and 
this  continues  until  the  placenta  has  been  expelled,  when  the 
pressure  again  rises  a  little.  As  a  rule,  however,  it  remains 
subnormal  until  about  the  fifth  day  of  the  puerperium,  after  which 
it  attains  gradually  the  normal  mean. 

It  is  exceedingly  likely  that  this  rise  of  blood  pressure  is  due  to 
some  altered  condition  of  the  blood,  and  that  it  may  be  regarded  as 
in  some  way  associated  with  the  hypertrophy  of  the  thyroid  gland 
which  takes  place  during  pregnancy,  and,  as  related  to  the  increased 
metabolic  activity  of  the  mother's  tissues,  the  result  of  the  presence 
of  the  growing  foetus  in  utero. 

Respiration. — As  might  be  expected,  there  is  an  increased  con- 
sumption of  oxygen  and  an  increased  discharge  of  carbonic  acid 
through    the   lungs   in    pi:egnancy — an    increase   which  has  been 


1 68  The   Practice  of   Midwifery. 

estimated  as  high  as  25  per  cent.  There  is  no  great  difference  in  the 
size  of  the  chest,  for  the  space  lost  by  diminution  of  depth  is  made 
up  for  by  increase  of  breadth  at  the  base  of  the  thorax.  Freedom  of 
respiration  is,  however,  interfered  with,  since  the  presence  of  the 
pregnant  uterus  limits  the  descent  of  the  diaphragm  in  inspiration. 
Thus  there  is  a  tendency  to  shortness  of  breath  towards  the  end  of 
pregnancy.  Provision  is  indeed  to  some  extent  made  by  nature  for 
this  liability,  since  it  is  presumed  to  be  with  a  reference  to  the 
contingency  of  pregnancy  that  in  women  respiration  is  habitually 
thoracic  rather  than  abdominal,  while  in  men  it  is  the  reverse. 

Puerperal  Osteophytes. — In  nearly  half  of  the  whole  number 
of  pregnant  women  calcareous  plates  are  formed  after  the  fifth 
month  on  the  interior  of  the  skull  in  the  neighbourhood  of  the 
vessels  between  the  dura  mater  and  the  bone,  and  these  have  been 
called  osteophytes  by  Rokitansky.  They  consist  chiefly  of  carbonate 
of  lime  with  a  large  proportion  of  organic  matter.  They  form 
irregular  plates  about  ^  inch  in  average  thickness,  connected  more 
intimately  with  the  bone  than  the  dura  mater. 

Hanau-"^  has  pointed  out  their  relationship  to  the  formation  of 
osteoid  tissue  in  other  parts  of  the  body,  and  is  inclined  to  attribute 
their  presence  to  a  slight  degree  of  osteomalacia. 

Urine. — The  quantity  of  urine  is  increased,  probably  in  conse- 
quence of  the  increased  arterial  pressure,  since  the  increase  is  found 
to  be  in  the  water  rather  than  the  solid  constituents.  The  occur- 
rence of  albuminuria  will  be  considered  among  the  disorders  of 
pregnancy.  Occasionally  a  very  small  quantity  of  sugar  is  found 
in  the  urine  in  the  later  months,  not,  however,  so  frequently  as  in 
women  who  are  suckling.  When  it  occurs  it  is  attributed  to  the 
resorption  of  sugar  from  milk  secreted  in  the  breasts,  although 
alimentary  glycosuria  may  undoubtedly  be  met  with,  and  the 
experiments  of  Lanz^  appear  to  show  that  the  power  of  assimilating 
the  sugar  contained  in  the  food  is  below  the  normal  in  pregnant 
women. 

The  amount  of  the  nitrogen  excreted  as  urea  is  in  healthy  women 
about  the  normal,  but  the  proportion  of  that  excreted  as  ammonia 
to  the  whole  is  slightly  increased.  The  total  amount  of  solids  is 
rather  below  the  normal,  and  this  is  brought  about  by  a  diminution 
in  the  amounts  of   uric   acid,  creatin,  creatinin,  phosphates,  and 

1  Hanau,  Fortschritt,  d.  Med.,  1892,  No.  7. 

2  Wien.  Med.  Presse,  1895,  No.  49. 


Changes   in  the   Maternal   Organism.        169 

sulphates  excreted,  while,  on  the  other  hand,  the  amount  of  chlorides 
excreted  is  increased. 

A  definite  storing  up  of  nitrogen  in  the  body  of  the  mother 
occurs,  no  doubt,  in  connection  with  the  growth  and  metabolism  of 
the  foetus.  This  is  seen  mainly  in  the  later  months  of  pregnancy, 
and  is  more  marked  in  multiparge  than  in  nulliparse.  The  experi- 
ments of  Hagemann^  and  others  have  demonstrated  that  in  bitches 
during  pregnancy  there  is  an  increased  excretion  of  nitrogen  in  the 
early  months  of  pregnancy,  and  that  an  amount  more  than  sufficient 
for  the  requirements  of  the  foetus  is  retained  in  the  body  of  the 
animal  in  the  later  months. 

A  peculiar  deposit  called  kyesteine,  first  described  by  Nauche,  is 
often  found  in  the  urine  of  pregnant  women,  if  allowed  to  stand  six 
or  seven  days  protected  from  dust.  It  is  a  product  of  decomposition, 
and  is  of  no  value  as  a  sign  of  pregnancy,  since  it  is  not  always 
present  in  pregnant  women,  and  may  be  found  under  other 
conditions,  and  in  the  male  sex. 

A  slight  degree  of  acetonuria,  not  exceeding  the  normal  physio- 
logical limit,  can  be  demonstrated  in  almost  all  pregnant  women, 
but  the  view  that  its  presence  is  a  sign  of  the  death  of  the  foetus  in 
utero  has  been  shown  to  be  untenable. 

According  to  Fischel,  small  quantities  of  peptone  can  be  recog- 
nised in  the  urine  during  pregnancy  as  well  as  in  the  puerperium ; 
the  significance  of  this  is  unknown,  and,  indeed,  other  observers 
have  thrown  some  doubt  on  the  correctness  of  Fischel's^  conclusions. 

Nervous  System. — The  irritability  of  the  nervous  centres  to 
reflex  stimuli  becomes  increased,  probably  as  part  of  the  physio- 
logical process  by  which  they  are  prepared  for  the  discharge  of 
nervous  energy  in  parturition.  By  deviations  from  this  normal 
process  arise  numerous  reflex  disturbances.  The  most  frequent  of 
these  are  disturbances  of  digestion,  especially  nausea  and  vomiting. 
Craving  for  food  is  naturally  more  frequent,  in  consequence  of  the 
increased  demands  upon  the  organism.  This  is  sometimes  con- 
verted into  longings  for  unusual  and  even  unpleasant  articles  of 
food,  and  thus  the  unnatural  longings  of  pregnancy  have  become 
popularly  known.  The  temper  may  be  changed,  so  that  an  amiable 
woman  becomes  irritable  and  peevish,  or  sometimes,  it  is  said,  the 
opposite  change  may  occur.  Other  frequent  nervous  disturbances 
are  hysteria,  neuralgia,  fainting  or  dizziness,  and  perversions  of 
special  senses.     Eruptions  such  as  acne  or  eczema  probably  depend 

'  Aichiv.  f.  Anat.  u.  Phys,,  Phys.  Abth.,  1890,  Hft.  516,  p.  577. 
■^  Fischol,  Zcritralbl.  f.  Gyniik,,  1889,  No.  27,  p.  473. 


lyo  The   Practice  of   Midwifery. 

also  mainly  upon  nervous  influence.  All  these  changes  are  depar- 
tures from  a  strictly  normal  condition,  and  will  be  further  considered 
among  the  disorders  of  pregnancy. 

Pigmentation. — There  is  a  tendency  to  pigmentation  in  other 
parts  beside  the  areolae  of  the  breasts,  and  in  individual  instances, 
chiefly  in  dark  women,  this  may  be  strongly  marked.  Most  women 
show  more  or  less  of  dark  rings  under  the  eyes.  The  abdomen, 
axillae  and  pubes  become  darker,  and  a  special  dark  band  is  formed 
along  the  linea  alba  from  the  ensiform  cartilage  to  the  pubes, 
surrounding  the  umbilicus  and  forming  the  umbilical  areola.  This 
dark  band,  however,  becomes  much  more  marked  after  delivery. 
In  rare  cases  the  face  is  disfigured  by  irregular  patches  of  a  dirty 
yellow  or  brownish  pigment,  the  so-called  chloasma  uterinum;  they 
are  met  with  more  especially  on  the  forehead,  the  bridge  of  the 
nose,  and  the  upper  lip.  It  may  be  in  origin  either  a  physiological 
or  a  sympathetic  pigmentary  disturbance. 


Chapter  IX* 
DIAGNOSIS  OF  PREGNANCY, 

It  is  of  obvious  importance  for  every  medical  man,  whatever 
may  be  his  branch  of  practice,  to  acquire  skill  in  the  diagnosis  of 
pregnancy,  since  almost  all  medical  and  surgical  diseases  are  liable 
to  be  modified  by  the  occurrence  of  that  state.  Moreover,  not  only 
may  it  be  of  extreme  importance  to  the  patient  to  obtain  a  correct 
opinion,  but  the  result  will  inevitably  make  manifest  to  all  con- 
cerned the  medical  man's  skill,  or  want  of  skill,  in  the  diagnosis. 
He  will  naturally  incur  ridicule  if  he  is  found  to  have  overlooked  or 
mistaken  an  advanced  pregnancy,  and  may  find  the  result  still 
more  unpleasant  if  he  erroneously  accuses  of  pregnancy  a  virtuous 
unmarried  woman. 

The  signs  of  pregnancy  may  be  divided  into  the  probable  or 
symptomatic  signs,  dej)ending  upon  the  changes  induced  in  the 
maternal  organism,  and  the  physical  or  direct  signs  afforded  by 
the  growth  of  the  uterus  and  the  ovum.  Of  these,  the  former  are 
sufficient  only  to  indicate  the  probability  of  pregnancy,  while  many 
of  the  latter  furnish  the  ground  for  an  absolute  diagnosis. 

Symptomatic  Signs  of  Pregnancy. 

Suppression  of  Menstruation. — The  cessation  of  menstruation 
is  commonly  the  first  sign  which  leads  a  woman  to  suspect  herself 
to  be  pregnant.  Its  significance  as  an  indication  of  probable 
pregnancy  is  most  when  the  woman  appears  perfectly  healthy, 
without  any  anaemia  or  chlorosis,  and  when  previous  menstruation 
has  been  regular  and  not  too  scanty.  A  short  period  of  amenorrhcea 
is  not  so  significant  as  a  longer  one.  The  amenorrhcea  is  valuable 
as  a  corroborative  sign  when  its  duration  corresponds  with  the 
indications  given  by  more  direct  signs,  such  as  the  enlargement  of 
the  uterus.  Irregular  hemorrhages  during  pregnancy  (really  due 
to  a  threatened  abortion)  may  be  mistaken  for  menstruation.  A 
more  genuine  menstruation  may  occur  within  the  first  three  months 
of  pregnancy,  while  there  is  still  a  space  between  the  decidua  vera 
and  the  decidua  reflexa,  the  decidual  cavity.  Cases  have  been  even 
reported  in  which  menstruation  has  continued  throughout  the  whole 


172  The  Practice  of   Midwifery. 

of  pregnancy,  although  it  is  extremely  rare  for  such  a  thing  to 
occur  at  regular  intervals.  In  such  a  case  the  blood  probably  comes 
from  the  decidua  in  the  lower  uterine  segment  in  the  early  months, 
and  from  the  cervix  uteri  in  the  later  months  of  pregnancy. 
Cazeaux  ^  has  recorded  the  case  of  a  woman  twenty-four  years  of  age 
who  menstruated  during  her  pregnancies  only  and  at  no  other 
time.  If,  however,  a  woman  who  imagines  herself  pregnant  men- 
struates regularly,  however  scantily,  there  is  a  strong  presumption 
that  the  pregnancy  is  not  genuine.  It  is  to  be  remembered,  on 
the  other  hand,  that  suppression  of  menstruation  may  occur  from 
various  emotional  and  other  causes  without  marked  disturbance  of 
health.  Temporary  cessation  of  menstruation  sometimes  occurs 
shortly  after  marriage  without  any  pregnancy,  and  the  same  thing 
may  happen  after  illicit  intercourse. 

The  occurrence  of  pregnancy  during  the  amenorrhoea  of  lactation 
is  not  common.  According  to  Eemfry  ^  it  occurs  in  only  6  per  cent., 
while  of  women  who  menstruate  regularly  while  suckling  it  occurs 
in  60  per  cent,  during  lactation.  Pregnancy  may  also  commence 
in  the  midst  of  periods  of  amenorrhoea  arising  from  other  causes, 
and  sometimes  even  in  the  case  of  women  who  have  never  men- 
struated at  all.  Special  care  is,  therefore,  required  not  to  overlook 
a  pregnancy  of  shorter  duration  than  would  correspond  to  the  date 
of  the  amenorrhoea.  The  medical  man  must  also  be  prepared  for 
possible  deception  on  the  part  of  the  woman.  Women  who  wish  to 
conceal  pregnancy  may  deny  the  suppression  of  the  menses,  and 
may  even  artificially  stain  their  linen  to  simulate  menstruation.  If 
they  confess  the  amenorrhoea,  they  may  give  it  an  incorrect  date, 
generally  a  more  recent  one  than  the  true. 

Morning  Sickness. — Nausea  and  vomiting  are  symptoms  which 
often  call  attention  to  the  probability  of  pregnancy,  especially  if 
they  occur  without  apparent  ill-health,  or  are  associated  with 
amenorrhoea,  or  with  obvious  enlargement  of  the  abdomen.  The 
nausea  or  vomiting  of  pregnancy  most  frequently  occurs  when  the 
woman  first  rises  in  the  morning,  and  is  met  with  in  about  two- 
thirds  of  all  pregnant  women.  Often  there  is  nausea  without  actual 
vomiting,  or  accomj)anied  merely  by  retching,  and  perhaps  the 
bringing  up  of  some  glairy  fluid.  These  symptoms  commonly 
begin  about  the  beginning  of  the  second  month,  and  are  relieved  or 
mitigated  at  the  end  of  the  fourth  month.^     They  may,  however, 

1  Cazeaux.  Traite  Theor.  et  Prat,  de  I'Art  des  Accouchements,  Paris,  1862. 

2  L.  Remfry,  Trans.  Obst.  Soc.  London,  1897,  Vol.  XXXVIll.,  p.  22. 

3  A.  Giles,  Ihid.,  1894,  Vol.  XXXIII.,  p.  303. 


Diagnosis  of   Pregnancy.  173 

commence  very  soon  after  conception,  and  may  also  continue  through 
the  later  months  of  pregnancy.  The  severer  forms  of  vomiting  will 
be  considered  among  the  disorders  of  pregnancy. 

Mammary  Changes. — The  changes  in  the  breast  and  their 
diagnostic  value  have  already  been  described  (pp.  164 — 166).  In 
every  doubtful  or  suspected  case  of  pregnancy  the  breasts  should 
be  observed,  and  it  is  often  convenient  to  make  this  the  first  step  in 
the  examination  of  the  patient. 


Physical  or  Direct  Signs  of  Pregnancy. 

Enlargement  of  the  Uterus  and  of  the  Abdomen. — For 
examination  of  the  abdomen,  the  patient  should  lie  on  her  back  on 
a  flat  couch,  with  a  small  pillow  under  her  head,  but  not  under  the 
shoulders.  The  thighs  should  be  flexed  and  somewhat  separated, 
so  as  to  obtain  the  greatest  possible  relaxation  of  the  abdominal 
muscles.  The  stays,  and  everything  tied  round  the  waist,  should 
be  unfastened,  and  the  skirts  slipped  down  so  as  to  uncover  the 
abdomen,  keeping  the  pubes  covered.  It  is  generally  of  advantage 
to  have  the  skin  actually  uncovered,  to  allow  ocular  inspection  of 
the  state  of  the  umbilicus,  and  of  any  pigmentation  which  may 
exist,  but  the  palpation  and  auscultation  may  be  carried  out,  if 
necessary,  through  a  thin  chemise  spread  fiat  over  the  surface.  If 
the  abdominal  muscles  are  rigid,  the  patient  should  be  directed  to 
look  up  to  the  ceiling,  letting  her  head  rest  easily  back  upon  the 
pillow,  and  her  attention  should  be  distracted  by  conversation 
while  the  pressure  of  the  hand  gradually  overcomes  the  muscular 
resistance. 

By  palpation  and  percussion  the  position  and  dimensions  of  the 
enlargement  formed  by  the  pregnant  uterus,  if  such  exists,  are 
made  out. 

Within  the  first  two  months  of  pregnancy  the  abdomen  may 
become  somewhat  flatter  than  before,  from  the  uterus  sinking 
lower  into  the  pelvis  through  its  increased  weight.  By  the  third 
month  there  begins  to  be  some  enlargement  in  the  lower  part  of 
the  abdomen.  It  is  generally  in  the  fourth  month  that  it  first 
becomes  possible  to  feel  the  enlarged  uterus  in  the  hypogastric  region 
by  external  examination  only. 

The  size  and  position  of  the  uterus  in  the  different  months  of 
pregnancy  have  already  been  described  (p.  153).  In  the  earlier 
months  the  consistence  of  the  uterus,  except  when  in  a  state  of 
contraction,  is  soft  and  elastic,  so  that  in  this  respect  it  is  liable  to 


174 


The  Practice  of   Midwifery. 


be  mistaken  rather  for  an  ovarian  cyst  or  fibro-cystic  tumour  than 
for  an  ordinary  fibroid  tumour  of  the  uterus.  Later  on,  its  con- 
sistence becomes  quite  characteristic,  and  is  sufficient  to  afford  a 
certain  diagnosis  of  pregnancy.  The  hand  receives  the  impression 
of  a  soHd  body — the  foetus,  floating  in  liquid — the  liquor  amnii. 
Near  the  end  of  pregnancy,  the  actual  parts  of  the  foetus,  the 
head,  the  back,  limbs,  and  breech,  may  be  made  out  by  palpation. 
Sometimes,  when  the  liquor  amnii  is  abundant,  especially  about 
the  sixth  or  seventh  month,  a  fluid  thrill  may  be  felt  through  it, 
resembling  that  which  may  be  observed  in  a  simple  ovarian  cyst. 


Fig.  118. — Method  of  bimanual  examination  of  uterus. 


To  estimate  the  enlargement  of  the  uterus  in  the  early  months 
the  bimanual  examination  is  necessary.  To  gain  the  full  benefit  of 
this,  the  bladder  must  be  empty,  and  in  a  case  of  any  doubt,  it  is 
important  to  secure  this  condition  by  passing  a  catheter.  If  a 
patient  is  very  nervous,  and  the  abdominal  muscles  very  rigid,  it 
may  in  rare  cases  be  necessary,  if  it  is  important  to  make  a  diagnosis 
at  once,  to  administer  an  anaesthetic  in  order  to  obtain  a  satisfactory 
result.  The  patient  is  still  to  be  in  the  dorsal  position,  as  for 
examination  of  the  abdomen.  The  physician,  standing  at  the  right 
side  of  his  patient,  passes  his  right  hand  beneath  the  thigh  and  intro- 
duces the  index  finger,  anointed  with  an  antiseptic  lubricant, 
into  the  vagina,  the  remaining  fingers  being  bent  well  back  upon 


Diagnosis  of   Pregnancy.  175 

the  palm.     The  fingers  of  the  left  hand,  without  any  intervening 
garment,  are  pressed  deeply  into  the  abdomen,  not  too  close  to  the 


Fig.  119.— Frozen  section  of  a  uterus  at  thirteenth  week  of  pregnancy  from  a 
patient  dying  of  heart  disease.  The  large  amount  of  decidua  in  the  lower 
uterine  segment,  and  the  decidual  cavity  are  well  seen.  There  are  minute 
hjemorrhages  into  the  placenta,  decidua  capsularis,  and  decidua  vera.i 

pubes,  and  endeavour  to  get  behind  the  fundus  and  bring  it  forward 
into  anteversion,  so  that  the  body  of  the  uterus  is  grasped  between 

'   Blacker,  Trans.  Obst.  Soc.  Lond.,  Vol.  42,  p.  235,  1900. 


176 


The  Practice  of   Midwifery. 


the  two  hands,  as  shown  in  Fig.  118.  If  there  is  any  difficulty 
about  doing  this,  the  finger  in  the  vagina  may  faciHtate  the 
manipulation  by  first  pushing  the  cervix  backw^ards  as  far  as 
possible.  If  the  cervix  is  beginning  to  ascend,  as  it  does  in  the 
course  of  the  third  and  fourth  months,  and  is  therefore  difficult  to 
reach,  the  middle,  as  well  as  index  finger,  may  be  introduced  into 
the  vagina,  and  an  additional  reach  of  about  a  quarter  of  an  inch 
thus  obtained. 

When  grasped  in  this  way  between  the  two  hands,  the  uterus 


Fig.  120. — Coronal  section  of  a  pregnant  uterus  at  the  twelfth  week  of 
pregnancy,  with  asymmetrical  enlargement  of  the  fundus  simulating  an 
extra  uterine  gestation.  A  well-marked  groove  was  present  between  the 
two  halves  of  the  uterus.  The  dotted  outline  shows  the  shape  of  the 
uterus  six  weeks  later.     (After  Piskaiek.) 


in  very  early  pregnancy  feels  more  anteflexed  and  more  anteverted 
than  usual,  and  the  increased  breadth  of  the  body  and  tendency  to 
a  globular  shape  may  be  made  out.  On  account  of  its  elasticity, 
the  pregnant  uterus  has  the  peculiar  character  that  its  outline  is 
not  so  easily  defined  as  that  of  a  uterine  enlargement  of  similar 
size  due  to  hyperplasia  or  fibroid  tumour.  On  this  account,  it 
may  be  missed  by  an  uniDractised  observer,  but  to  a  skilled  person, 
this  very  quality  is  the  most  characteristic  of  pregnancy.  If  an 
occasional  hardening,  due  to  the  intermittent  uterine  contractions 
which  will  be  mentioned  hereafter,  can  be  detected,  the  diagnosis 


Diag-nosis  of   Pregnancy. 


177 


is  still  further  confirmed.  The  uterus,  if  unimpregnated,  can  be 
rolled  between  the  fingers,  and  the  absence  of  enlargement  posi- 
tively made  out.  Other  kinds  of  enlargement,  due  to  hyperplasia 
or  tumour,  are  generally  distinguished,  not  only  by  their  greater 
hardness,  but  by  being  associated,  not  with  amenorrhcea,  but 
frequently  with  menorrhagia. 


Hegar's  Sign. — Another  special  character  of  the  uterus  in 
early  pregnancy,  to  be  discovered  on  bimanual  examination,  is 
known  as  Hegar's  sign  of  pregnancy.  This  consists  of  a  change 
in  consistency  of  that  part  of 
the  uterus  which  is  just  above 
the  cervix,  and  below  the 
expanded  portion  of  the  body. 
This  segment  becomes  soft, 
thin,  yielding,  and  compres- 
sible, while  the  cervix  below 
and  fundus  above  are  com- 
paratively firm,  the  former 
being  harder  and  the  latter 
more  elastic.  The  compres- 
sible part  corresponds  to  the 
portion  of  the  body  of  the 
uterus  below  the  ovum 
occupied  only  by  soft  spongy 
decidua  (Fig.  119).  In  ex- 
treme cases  the  continuity 
between  cervix  and  fundus 
becomes  obscured,  and  the 
impression  is  given  of  a 
separation  between  them.  In 
some  instances  this  has  led  to  an  erroneous  diagnosis  of  extra- 
uterine pregnancy :  a  hypertrophied  cervix  being  mistaken  for  the 
whole  uterus,  and  the  fundus,  flexed  to  one  side,  for  an  extra-uterine 
sac  (Fig.  120).  This  compressibility  of  the  lower  uterine  segment 
is  present,  according  to  Dickenson,  in  two-thirds  of  all  cases.  A 
definite  bulging  of  the  uterine  wall  at  the  site  of  the  attachment  of 
the  ovum  is  also  very  characteristic  :  it  can  be  felt  more  readily 
when  the  implantation  of  the  ovum  is  on  the  anterior  wall  of  the 
uterus ;  but  it  may  be  felt  posteriorly  or  at  the  sides  of  the  uterus 
in  the  region  of  the  tubes  (Fig.  121). 


Fia.  121. — Sagittal  section  of  a  pregnant 
uterus  at  the  fourth  to  the  fifth  week  of 
pregnancy.  The  bulging  of  the  anterior 
wall  is  well  marked,  and  the  relatively 
increased  resistance  of  the  posterior 
wall  and  the  compressibility  of  the 
lower  uterine  segment  (Hegar's  sign) 
are  shown  diagrammatically.  (After 
Piska  ek.)i 


1   I'iskaijek    UeVjer    Ausladungcn   umschricbener   Geblirmutter   abschnitte. 
1899. 

M.  12 


Wien. 


178 


The  Practice  of   Midwifery. 


In  a  certain  number  of  early  pregnancies  the  portion  of  the  wall 
of  the  uterus  corresponding  to  the  site  of  the  ovum  forms  an  elastic 
bulging  mass,  while  the  remainder  of  the  uterine  wall  is  hard, 
resistant,  and  distinct  in  outline.  Not  uncommonlj'-  the  two 
portions  are  separated  from  one  another  by  a  definitely  recognisable 
furrow  or  ridge. 

Another  sign  of  early  pregnancy,  to  which  Sellheim  in  particular 
has  drawn  attention,  is  the  possibility  of  wrinkling  or  folding  up 
by  manipulation  the  outer  layer  of  muscle  tissue  in  the  wall  of  the 
uterus,  especially  on  its  posterior  surface.     This  is  due  to  the  marked 


Fig.  122. — Demonstration  of  Hegar's  sign  by  bimanual  examination, 
the  uterus  being  anteverted. 

softening  of  the  muscle  layers  and  to  the  increased  mobility  of  the 
outer  layers  upon  the  inner,  which  are  firmly  attached  to  the  ovum. 

These  signs  are  of  most  value  from  the  sixth  to  the  eighth  or 
tenth  week  of  j)regnancy. 

In  order  to  recognise  them,  the  best  mode  of  examination  is 
that  shown  in  Fig,  122,  the  external  hand  being  placed  behind  the 
fundus  so  as  to  bring  the  uterus  into  anteversion,  and  the  internal 
finger  being  placed  in  front  of  the  cervix.  Sometimes,  however, 
this  cannot  be  done  without  the  administration  of  an  anaesthetic, 
when  the  uterus  is  retroverted.  Then  the  external  hand  may  be 
placed  in  front  of  the  fundus,  which  is  pushed  back,  and  the 
vaginal  finger  behind  the  cervix  (Fig.  123).     Another  plan  is  to 


Diagnosis  of  Pregnancy. 


179 


place  the  index  finger  in  the  rectum  and  the  thumb  in  the  vagina, 
while  the  external  fingers  are  pressed  in  as  shown  in  Fig.  123. 

If  the  elastic  enlargement  of  the  fundus  above  described  can  be 
ascertained,  especially  if  Hegar's  sign  be  present,  if  it  agrees  in 
size  with  the  duration  of  amenorrhoea,  and  if  in  addition,  in  a 
nulliparous  woman,  a  little  mucoid  secretion  can  be  squeezed  from 
the  breasts,  a  practically  certain  diagnosis  of  pregnancy  may  be 
made  even  within  the  first  two  or  three  months.  The  medical 
man  will,  however,  do  well  not  to  commit  his  credit  by  an  absolutely 
positive  opinion  until  he  obtains  the  more  certain  signs  of  the  foetal 


Fig.  123.- 


-Demonstration  of  Hegar's  sign  by  bimanual  examination, 
the  uterus  being  retro  verted. 


heart-sounds,  foetal  movements,  or  ballottement.  This  method  of 
diagnosing  pregnancy  by  the  bimanual  examination  of  the  uterus 
depends  greatly  upon  the  tactus  eriulitus  gained  by  practice,  and  it 
frequently  happens  that  the  inexperienced  overlook  a  pregnancy  of 
as  much  as  three  months'  standing,  or  even  longer.  The  student 
should  therefore  lose  no  opportunity  of-  becoming  familiar  with  the 
feel  of  the  uterus  in  the  early  stage  of  pregnancy.  The  only  con- 
dition in  which  this  method  of  examination  fails  to  afford  a  good 
result,  is  when  the  fundus  uteri  is  partially  retroverted  or 
retroflexed,  so  that  it  is  impossible  to  get  the  fingers  of  the  external 
hand  sufficiently  behind  the  uterus  to  bring  it  forward  into  a  position 
of  anteversion,  and  when  the  abdominal  walls  are  also  rigid  or 

12—2 


i8o  The  Practice  of   Midwifery. 

loaded  with  fat.     Even  then,  the  administration  of  an  anaesthetic 
would  generally  overcome  the  difficulty. 

Changes  in  the  Cervix  Uteri  and  Vagina. — The  diagnostic 
value  of  the  changes  in  the  cervix  and  vagina  has  already  been 
described  (pp.  155 — 161).  It  is  especially  important  to  ascertain 
whether  the  degree  of  change  discovered  corresponds  to  the  date 
of  pregnancy  as  estimated  by  the  size  of  the  uterus,  determined  by 
bimanual  or  abdominal  examination.  Towards  the  end  of  pregnancy 
in  multipara,  the  finger  may  often  be  passed  through  the  cervix 
into  the  uterus,  and  feel  the  membranes  and  presenting  part  of  the 
foetus.  If  there  is  a  difficulty  in  reaching  the  cervix  sufficiently  to 
observe  its  softening  and  apparent  shortening  after  the  third  or 
fourth  month  of  pregnancy,  when  it  rises  to  a  greater  distance  from 
the  vulva,  it  is  a  good  plan  to  make  the  patient  turn  on  to  her  left 
side,  if  the  examination  is  being  made  with  the  right  hand.  It  is 
then  possible  to  retract  the  perineum  more  thoroughly,  and  thus  to 
reach  to  a  higher  level  in  tlie  hollow  of  the  sacrum. 

Violet  Coloration  of  Cervix  and  Vagina.  —  Besides  the 
changes  in  the  cervix  itself,  the  enlarged  uterine  arteries  may  be  felt 
pulsating  in  the  lateral  fornices.  These,  however,  may  be  found 
also  in  the  case  of  periuterine  inliamuiation,  as  well  as  in  that  of 
tumours,  especially  hbroid  tumours  of  the  uterus.  A  sign  of  more 
importance  is  to  be  found  in  the  violet  coloration  of  the  cervix  uteri, 
vagina,  and  vulva.  The  colour  differs  from  that  produced  by  active 
congestion  or  inflammation  of  the  mucous  membrane  by  its  bluer 
tint,  due  to  its  being  the  effect  of  venous  obstruction,  the  result  of 
pressure.  The  blue  tint  is  first  to  be  recognised  in  the  cervix  itself, 
and  hence  it  is  sometimes  an  assistance  to  diagnosis,  within  the  first 
three  months  of  pregnancy,  to  examine  the  cervix,  with  a  Ferguson's 
speculum.  A  similar  appearance,  however,  may  result  from  the 
pressure  of  a  tumour. 

Intermittent  Uterine  Contractions. — Throughout  pregnancy 
gentle  painless  contractions  of  the  uterus  take  place  at  intervals 
by  discharge  of  centric  nervous  force,  and  similar  contractions  may 
often  be  excited  by  manipulation  of  the  uterus.  That  they  do  not, 
however,  solely  depend  upon  external  stimulus,  is  proved  by  the 
fact  that  the  uterus  may  sometimes  be  found  tense  when  the  hand 
is  first  laid  upon  it.  The  tense  condition  generally  lasts  for  a  minute 
or  two,  resembling  in  its  duration  a  labour  pain.  It  may  be 
possible  to  detect  the  alternate  contraction  and  relaxation  of   the 


Diag-nosis  of   Pregnancy.  i8i 

uterus  as  soon  as  it  comes  into  contact  with  the  abdominal  wall, 
and  it  becomes  more  and  more  easy  to  do  so  as  pregnancy  advances. 
It  may  often,  however,  be  necessary  to  watch  the  case  for  some 
time,  and  make  repeated  examinations,  before  a  decisive  result  is 
obtained.  In  the  intervals  of  relaxation  the  uterus  lies  flaccid 
under  the  action  of  gravity,  its  outline  is  indistinct,  and  the  foetus, 
if  large,  can  be  easily  felt  through  its  walls.  During  a  contraction 
it  resumes  more  or  less  its  true  pyriform  shape,  so  that  it  becomes 
more  prominent  in  front,  its  boundaries  become  definite,  and  the 
tenseness  of  its  surface  prevents  the  parts  of  the  foetus  from  being 
distinctly  felt.  If  this  sign  is  obtained  in  a  strongly  marked 
degree,  it  is  proved  not  only  that  pregnancy  of  some  sort  exists, 
but  that  it  is  intra-uterine.  In  the  case  of  a  soft  fibroid  tumour, 
variations  of  density  may  take  place  owing  to  uterine  contractions, 
but  these  are  never  so  strongly  marked  as  the  more  characteristic 
changes  which  may  be  observed  in  a  pregnant  uterus.  Similar 
changes  might  conceivably  occur  in  a  distended  bladder,  but  have 
not  been  observed  in  it,  andit  seems  that  the  bladder,  when  over- 
distended,  loses  its  contractile  power.  The  j)regnant  uterus,  when 
in  an  irritable  state,  sometimes  remains  continuously  in  a  partially 
contracted  and  tense  condition,  and  it  may  then  be  impossible  to 
detect  alterations  of  tenseness  in  its  walls.  The  failure,  therefore, 
after  repeated  attempts,  to  detect  contractions,  does  not  prove  that 
any  given  swelling  is  not  the  uterus,  although,  if  the  presumed 
pregnancy  is  at  an  advanced  stage,  it  should  always  excite  suspicion 
on  this  point. 

There  are  two  cases  in  which  this  sign  is  of  special  value.  The 
first  is  when  an  irregular  tumour  exists,  and  there  is  doubt  whether 
a  part  or  the  whole  of  it  is  formed  by  the  pregnant  uterus.  If  the 
hardening  of  contraction  extends  over  the  whole  mass,  it  is  proved 
that  the  whole  of  it,  however  irregular,  consists  of  the  uterus.  The 
second  case  is  that  of  an  excess  of  liquor  amnii,  when  the  foetus  is 
too  small  to  give  signs  of  its  life,  and  the  pregnant  uterus  may  be 
mistaken  for  an  ovarian  cyst,  and  is  liable  even  to  be  tap]3ed  under 
such  a  mistaken  diagnosis. 

Ballottement. — By  ballottement  {hallotter,  to  toss  up  like  a  ball) 
is  meant  the  sensation  imparted  to  the  fingers  when  they  are  placed 
beneath  or  at  the  sides  of  the  foetus,  and,  as  it  were,  toss  it  up  or 
about  in  the  liquor  amnii.  There  are  two  kinds  of  ballottement, 
internal  and  external,  of  which  the  internal  is  the  most  valuable  as 
a  sign  of  pregnancy.  Internal  ballottement  is  obtained  in  the 
following  manner  :   The  woman  is  placed  in  the  dorsal  position,  the 


1 82  The  Practice  of   Midwifery. 

index  finger,  or  two  fingers,  of  one  hand  are  introduced  into  the 
vagina,  while  the  fundus  is  pressed  down  by  the  other  hand  or  by  an 
assistant.  The  uterus  is  brought  into  the  most  favourable  position 
if  the  woman  takes  a  deep  breath,  and  then  holds  her  breath  for  a 
moment.  The  finger  in  the  vagina,  with  its  tij)  resting  just  in  front 
of  the  cervix,  then  gives  a  sudden  but  gentle  push  or  jerk  upwards. 
The  hard  foetal  head,  which  is  usually  resting  at  this  spot,  is  felt  to 
recede  from  the  finger,  and  after  a  moment's  interval,  to  return  with 
a  gentle  tap.  This  constitutes  the  complete  sign  of  ballottement 
{choc  en  retour,  ballottement  double),  but  sufficiently  characteristic 
evidence  may  often  be  obtained  even  if  a  distinct  return-tap  cannot 
be  made  out,  provided  that  the  hard  body  can  be  felt  to  recede,  and, 
after  a  moment  or  two,  to  have  returned  to  its  former  position.  If 
the  foetal  head  does  not  rest  in  front  of  the  cervix  when  the  woman 
is  horizontal,  it  may  often  be  made  to  do  so,  and  to  give  the  sign  of 
ballottement,  if  she  is  placed  in  a  reclining  position,  with  the 
shoulders  and  head  raised  but  supported  by  pillows,  so  that  the  axis 
of  the  uterus  is  nearly  vertical,  or  its  upper  extremity  inclined 
somewhat  forward.  If  this  also  fails,  the  finger  may  be  introduced 
into  the  vagina  as  the  woman  stands  uj^right.  If  any  other  part 
than  the  head  is  presenting,  internal  ballottement  cannot  so  easily 
be  obtained.  Ballottement  is  chiefly  available  from  the  end  of  the 
fourth  to  the  seventh  month,  and  is  most  marked  about  the  middle 
of  that  period.  It  may  sometimes  be  obtained  in  the  latter  half  of 
the  fourth  month,  earlier  than  it  is  possible  to  detect  the  foetal 
heart-sounds,  and  it  is  at  this  early  stage  that  this  sign  is  most 
valuable.  In  the  last  two  months  of  pregnancy,  the  quantity  of 
liquor,  amnii  becomes  relatively  too  small  to  allow  the  foetus  to  be 
tossed  up,  but  the  hard  foetal  head,  if  presenting,  may  be  felt 
through  the  uterine  wall  by  the  finger  placed  in  front  of  the  cervix, 
and  may  be  moved  by  it  to  some  extent. 

Internal  ballottement  is  a  positive  sign  of  pregnancy,  though  not 
of  the  life  of  the  foetus,  if  detected  by  a  skilled  observer.  An  in- 
experienced person  might  possibly  mistake  an  anteflexed  fundus 
uteri,  especially  if  associated  with  ascites,  for  the  foetal  head  ;  but 
the  anteflexed  fundus  would  not  give  the  distinct  return-tap  upon 
the  finger  after  tossing  ujd  which  makes  the  sign  of  ballottement 
complete. 

External  ballottement  is  obtained  in  the  following  manner  :  The 
woman  is  placed  in  the  dorsal  position,  with  the  abdomen  exposed 
or  only  lightly  covered  ;  one  hand  is  placed  on  either  side  of  the 
uterus,  and  by  a  light  quick  movement  of  the  fingers  one  or  other 
part  of  the  foetal  body  may  be  made  to  recede  and  often  to  impinge 


Diagnosis  of  Pregnancy.        183 

upon  the  opposite  hand.  In  some  instances  only  an  irregular  mass 
may  be  felt  which  can  be  moved  to  and  fro.  This  sign  can  be 
best  obtained  when  the  breech  is  presenting  and  the  head  is  at  the 
fundus.  External  ballottement  can  be  made  out  to  some  degree  as 
soon  as  the  uterus  is  in  contact  with  the  anterior  abdominal  wall, 
and  it  is  a  very  characteristic  sign  of  pregnancy  when  definitely 
present.  It  may  be  obtained  also  in  the  following  manner,  and  this 
method  is  particularly  useful  in  cases  of  hydramnics  where  the 
excess  of  liquor  amnii  may  obscure  the  parts  of  the  foetus.  The 
patient  is  placed  in  the  lateral  or  semi-prone  position,  so  that  the 
uterus  rests  against  the  couch,  or  overhangs  its  edge.  One  hand  is 
placed  above  the  uterus  to  steady  it,  while  the  fingers  of  the  other 
are  laid  flat  beneath  the  uterus  at  any  point  where  a  firm  portion  of 
the,foetus  can  be  felt,  and  give  it  a  jerk  upwards,  as  in  the  case  of 
internal  ballottement. 

Foetal  Movements. — Foetal  movements  probably  commence  at 
a  very  early  stage  in  the  development  of  the  muscular  system  of 
the  embryo.  They  are  generally  first  felt  by  the  mother  about  the 
eighteenth  to  the  twentieth  week,  but  the  time  when  this  occurs  is 
very  variable.  The  first  feeling  of  the  foetal  movements,  which  is 
known  by  the  name  of  quickening,  is  supposed  to  depend  upon  the 
uterus  having  risen  sufficiently  into  the  abdomen  to  come  into 
contact  with  the  abdominal  walls.  The  unaccustomed  sensation, 
when  first  felt,  especially  in  first  pregnancies,  often  gives  rise  to 
a  feeling  of  faintness,  or  other  disagreeable  nervous  symptoms. 
As  pregnancy  advances,  the  motions  become  more  and  more 
manifest ;  in  the  later  months  they  may  often  be  seen  as  well 
as  felt,  and  can  readily  be  excited  by  stimulating  the  foetus  with 
pressure  through  the  abdominal  wall.  Foetal  movements  may 
be  heard  on  auscultation  before  they  are  recognised  by  the 
mother,  and  before  the  foetal  heart  is  audible.  The  sound  at  first 
is  a  faint  thud,  later  in  pregnancy  louder  thuds  or  taps  may  be 
heard,  and  sometimes  loud  scratching  or  rubbing  noises,  as  the 
foetal  extremities  scrape  against  the  interior  of  the  uterus.  They 
occur  in  some  patients  with  extreme  frequency.  When  pregnancy 
is  somewhat  advanced,  an  impulse  against  the  stethoscope  may 
often  be  felt  accompanying  the  sound.  The  movements  may 
sometimes  be  felt  from  the  abdomen  by  the  physician  before  the 
mother  feels  them,  and  at  an  earlier  stage  still,  before  the  uterus 
has  come  into  contact  with  the  abdomen,  they  may  sometimes 
be  felt  from  the  vagina,  or  on  bimanual  examination.  Move- 
ments may  be  felt  in  this  way  from  the  vagina  as  early   as  the 


184  The   Practice  of   Midwifery. 

beginning  of  the  fourth  month,  and  may  be  heard  on  auscultating 
the  abdomen  about  the  middle  of  the  fourth  month. 

Recognition  of  foetal  movements  is  of  great  value  in  diagnosis, 
for  it  proves  not  only  pregnancy,  but  the  presence  of  a  living  foetus, 
and  often  it  does  this  when  the  foetal  heart  cannot  be  heard.  The 
subjective  sign  of  quickening  is  of  little  or  no  value,  for  some- 
times women  fail  to  perceive  the  movements  up  to  quite  a  late 
period  of  pregnancy.  More  frequently,  even  women  who  have 
borne  several  children  mistake  intestinal  movements  for  those  of 
a  foetus,  and  on  this  ground  become  firmly  convinced  that  they 
are  pregnant.  Even  the  physician  will  find  a  faint  sound  of 
foetal  movement  more  difficult  to  be  certain  about  than  the  sound 
of  the  foetal  heart,  and  must  take  care  not  to  mistake  for  it  either 
movements  of  the  abdominal  muscles  or  those  of  the  intestines. 

« 

The  sign  is  greatly  confirmed  if  the  movements  can  be  felt  as  well 
as  heard.  There  is  one  case  in  which  the  recognition  of  foetal 
movements  by  feeling  from  the  vagina  is  of  special  value.  This  is 
when  pregnancy  is  complicated  by  an  abdominal  tumour,  which  may 
prevent  the  fundus  uteri  from  coming  into  contact  with  the  abdominal 
walls  up  to  a  much  later  period  than  usual,  so  that  the  usual  signs, 
on  auscultating  the  abdomen,  are  entirely  absent,  and  even  the  en- 
largement of  the  fundus  uteri  may  be  obscured  by  the  presence  of 
the  tumour. 

Uterine  Souffle. — The  uterine  souffle  is  a  soft  blowing  murmur, 
synchronous  with  the  maternal  pulse  and  present  in  about  99  per 
cent,  of  all  pregnant  women.  It  is  generally  heard  on  one  or  both 
sides  of  the  uterus,  rather  low  down,  over  the  position  of  the 
uterine  arteries,  but  sometimes  it  is  audible  over  a  considerable  i^art 
of  the  fundus.  It  was  formerly  called  the  placental  souffle,  from 
the  belief  that  it  had  its  origin  in  the  placenta.  This  is  disproved 
by  the  fact  that  it  may  be  heard  for  some  days  after  delivery,  with 
diminishing  intensity,  and  that  a  similar  souffle  may  be  heard  in 
some  cases  of  uterine  tumour.  It  is  now  generally  agreed  that  the 
uterine  souffle  has  its  origin  in  the  large  arterial  branches 
approaching  the  uterus  from  the  broad  ligaments  and  entering  the 
uterine  walls.  No  certain  inference  can  be  derived  from  it  as  to 
the  position  of  the  placenta.  The  arteries,  however,  are  most 
developed  in  the  neighbourhood  of  the  placenta,  and  if  the  souffle 
is  heard  widely  over  the  fundus  in  front,  there  is  a  certain  presump- 
tion in  favour  of  the  placenta  being  attached  in  front.  The 
converse  inference  must  not  be  drawn  from  the  absence  of  a  souffle 
in  front.     The  souffle  is  physically  explained,  partly  by  the  presence 


Diagnosis  of   Pregnancy.  185 

of  many  large  arterial  branches  having  tortuous  courses,  and 
partly  by  the  deteriorated  quality  of  the  blood  in  some  women  in 
pregnancy,  which  renders  it  more  prone  to  generate  a  murmur,  as 
in  the  case  of  the  arterial  and  venous  murmurs  of  anaemia.  The 
soufSe  is  loudest  when  the  blood  deterioration  is  greater  than  usual. 
In  some  such  cases  the  murmur  can  be  distinguished  as  being 
double,  the  second  and  fainter  element  corresj)onding  to  the  dicrotic 
wave  of  the  pulse.  The  uterine  souffle  differs  slightly  from  the 
murmur  produced  by  pressure  on  a  large  artery  in  that  it  swells 
and  dies  away  more  gradually,  and  is  generally  softer.  This 
probably  is  due  to  its  being  produced  in  a  number  of  arterial 
branches  of  various  sizes.  It  has  been  comj)ared  to  the  puffing  of 
the  engine  of  a  goods-train  going  slowly,  and  heard  from  a  distance. 
The  uterine  souffle  of  pregnancy  has  also  the  special  character  that 
it  is  very  variable  at  different  times  in  the  same  person.  This 
character  appears  to  depend  mainly  upon  the  effect  of  contractions 
of  the  uterus,  and  partly  also  upon  changes  in  its  position.  As  a 
uterine  contraction  comes  on,  the  souffle  becomes  raised  in  pitch, 
and  thereby  often  for  a  time  louder,  sometimes  even  almost 
whistling  in  tone.  As  the  contraction  reaches  its  height,  it  becomes 
fainter,  and  may  be  even  suppressed,  resuming  its  original  quality 
as  the  pain  passes  off.  The  souffle  may  sometimes  be  modified  to 
some  extent  by  pressure  with  the  stethoscope,  and  has  been  felt 
occasionally  as  a  thrill  by  the  finger. 

The  uterine  souffle  may  be  heard  towards  the  end  of  the  fourth 
month,  and  therefore  generally  earlier  than  the  fcetal  heart-sounds, 
some  say  even  as  early  as  the  eighth  or  ninth  week.  In  the  early 
months  it  must  be  sought  for  by  placing  the  stethoscope  close  above 
the  pubes  at  either  side,  and  pressing  it  deep  down  to  reach  the 
sides  of  the  uterus.  The  souffle  is  of  considerable  value  in  the 
diagnosis  of  jDregnancy,  especially  in  the  earlier  months,  when  the 
foetal  heart  cannot  be  detected.  It  is  true  that  it  may  be  heard  in 
uterine  tumours,  but  these  are  rarely  associated  with  amenorrhoea. 
Moreover,  a  tumour  equal  in  size  to  a  uterus  pregnant  less  than 
four  and  a  half  months  rarely  gives  a  souffle.  If  the  souffle  is  found 
to  have  marked  variations  of  quality  and  loudness,  tlie  presumption 
of  pregnancy  is  increased,  for  tumours  are  not  subject  to  such 
marked  contraction  as  the  pregnant  uterus.  A  souffle  may  be  heard 
in  extra-uterine  pregnancy,  but  not  so  constantly  as  in  normal 
pregnancy;  and,  if  heard,  it  would  not  be  so  likely  to  vary  in  quality. 

Fcetal  Heart- Sounds. — The  foetal  heart-sound  is  double,  like 
that  of  a  heart  in  after-life,  but  the  distinction  in  quality  between 


1 86  The  Practice  of   Midwifery. 

the  two  sounds  is  not  so  marked.  When  the  heart  is  heard  only 
faintly,  the  first  sound  alone  may  be  audible.  The  quality  of  the 
sound  has  been  compared  to  that  of  a  watch  (not  a  lever  watch) 
ticking  underneath  a  pillow.  The  student  can,  however,  best  learn 
it  by  listening  to  the  heart  of  an  infant  soon  after  birth.  The  rate 
generally  varies  between  120  and  160  in  the  minute.  It  has  often 
been  stated  that  the  rate  is  most  rapid  when  the  heart-sounds  first 
begin  to  be  heard,  while  the  foetus  is  still  very  small,  and  that  it 
diminishes  in  rapidity  with  the  advance  in  pregnancy.  In  reahty, 
however,  there  is  no  marked  progressive  change.  The  rapidity  of 
the  heart  is  much  increased,  sometimes  as  much  as  twenty  beats 
in  the  minute,  by  active  fcetal  movements.  It  varies  also  to  some 
extent  in  accordance  with  the  condition  of  the  mother.  When  the 
maternal  pulse  is  rapid  on  account  of  fever,  the  rate  of  the  foetal 
heart  may  be  increased  also,  although  not  in  anything  like  the  same 
proportion:  As  in  the  case  of  the  adult  heart,  an  elevation  of  the 
blood-pressure  makes  the  heart's  rapidity  less.  In  the  case  of  the 
foetus,  the  blood-pressure  is  chiefly  liable  to  be  affected  by  pressure 
upon  the  funis  and  placenta.  Thus,  during  a  labour  pain,  the  foetal 
heart  becomes  slower,  and  resumes  its  former  rapidity  when  the 
pain  is  over.  During  a  head-last  delivery,  when  the  funis  is 
pressed  upon,  the  foetal  pulse-rate,  as  observed  in  the  funis,  may 
become  very  slow,  and  a  sudden  and  great  increase  of  rapidity 
may  then  sometimes  be  noticed  the  instant  the  head  is  liberated. 
The  foetal  heart-rate  also  becomes  slower  as  the  vitality  of  the 
foetus  is  becoming  exhausted  by  prolonged  pressure  in  delivery ;  and 
thus,  in  protracted  labour,  as  the  mother's  pulse  becomes  gradually 
more  rapid,  the  foetal  heart  becomes  gradually  slower.  The 
pressure  on  the  funis  and  placenta  leads  also  to  diminished 
oxygenation  of  the  foetal  blood,  and  so  to  stimulation  of  the  vagus, 
and  further  slowing  of  the  foetal  heart.  This  change  of  rapidity 
affords  a  valuable  sign  of  danger  to  the  child's  life.  In  these  cases 
the  heart  only  gradually  returns,  after  delivery,  to  its  former 
rapidity  or  nearly  so.  The  foetal  heart-sounds  can  generally  be 
detected  for  the  first  time  in  the  course  of  the  fifth  month  of 
pregnancy,  mostly  from  the  eighteenth  to  the  twentieth  week. 
In  unusually  favourable  circumstances,  they  may  be  heard  as 
early  as  the  fifteenth  or  sixteenth  week,  and  they  become 
progressively  louder  as  pregnancy  advances. 

The  fcetal  heart-sounds  are  by  far  the  most  valuable  of  all  the 
signs  of  pregnancy.  If  they  are  recognised,  it  is  proved  that 
pregnancy  exists  with  a  living  foetus,  and  the  only  possible  further 
doubt  that  could  arise  is  whether  the  pregnancy  is  normal  or  extra- 


Diagnosis  of   Pregnancy.  187 

uterine.  If,  then,  the  presumed  pregnancy  has  reached  the  fifth 
month,  it  is  well  to  make  the  listening  for  the  foetal  heart  one  of  the 
early  steps  of  the  examination.  If  it  is  detected,  only  a  confirmation 
of  the  pregnancy  being  intra-uterine  is  required,  and  this  is  to  be 
found  in  the  changes  of  the  cervix,  the  characters  of  the  uterine 
tumour,  audits  alternate  contraction  and  relaxation.  To  listen  for  the 
foetal  heart,  perfect  quiet  in  the  room  must  be  secured,  and  any 
ticking  clock  should  be  stopped.     The  stethoscope  should  be  pressed 


o  o 


I  y  i 

Fig.  124. — Diagram  showing  the  areas  in  which  the  foetal  heart  sounds  are 
heard  with  greatest  intensity  in  vertex  and  breech  presentations.  The 
upper  circles  indicate  the  area  of  maximum  intensity  in  the  first  and 
second  breech  presentation,  the  inner  of  the  lower  two  circles  in  the  first 
and  second  vertex,  and  the  outer  in  the  third  and  fourth.  The  two  latter 
circles  are  a  little  too  far  forwards. 

gently  upon  the  abdomen  by  resting  the  ear  upon  it,  and  should 
not  be  held  by  the  fingers,  or  allowed  to  touch  the  clothes.  Some 
prefer  a  binaural  stethoscope,  as  intensifying  sound,  but  I  have 
often  found  it  fail  to  reveal  the  foetal  heart  when  an  ordinary 
wooden  stethoscope  succeeds,  probably  because  muscular  sounds 
are  more  liable  to  create  confusion  in  the  binaural.  The  foetal 
heart  should  always  be  counted,  and  it  should  be  noted  whether 
the  rate  remains  tolerably  constant  in  successive  quarters  of  a 
minute.  If  it  cannot  be  counted,  the  sign  must  be  regarded  as 
unco^rtain. 


1 88  The   Practice  of   Midwifery. 

The  heart-sounds  are  transmitted  best  through  the  back  of  the 
foetus  when  tbe  foetus  is  in  its  usual  attitude.  In  the  early  months 
the  fcetal  heart-sounds  are  most  readily  heard  in  the  middle  line 
between  the  symphysis  and  the  umbilicus.  However,  toward  the 
latter  part  of  pregnancy,  if  the  foetus  is  lying  in  the  first  position, 
with  its  back  towards  the  left  side,  as  it  is  in  the  great  majority  of 
cases  (see  Fig.  124,  p.  187),  the  likeliest  place  to  hear  the  foetal 
heart  is  about  half-way  between  the  umbilicus  and  the  centre  of 
Poupart's  ligament  on  the  left  side.  If  it  is  lying  in  the  second 
position,  with  its  back  toXvards  the  right  side,  the  heart  is  heard  best 
in  the  corresponding  position  on  the  right  side.  When  the  foetus 
is  presenting  by  the  breech,  the  foetal  heart  is  heard  best  relatively 
higher  up,  at  the  level  of  or  even  above  the  umbilicus,  in  proportion 
to  the  size  of  the  uterus  (Fig.  124).  In  face  i^resentations,  it  is 
heard  through  the  thorax  better  than  through  the  back.  In  any  other 
than  a  face  presentation,  when  the  back  of  the  foetus  is  lying  back- 
ward, and  the  limbs  with  a  good  deal  of  liquor  amnii  intervene 
between  its  trunk  and  the  surface  of  the  uterus,  the  foetal  heart  is 
heard  less  distinctly,  and  sometimes  not  heard  at  all.  If,  therefore, 
it  is  not  heard  at  the  first  attempt,  repeated  trials  should  be  made 
on  different  occasions,  and  it  must  not  be  assumed  that  the  child 
is  necessarily  dead,  if  the  foetal  heart  appears  for  a  time  to  have 
disappeared.  In  order  to  catch.the  foetal  heart-sounds  at  an  early 
stage  of  pregnancy,  a  great  deal  depends  upon  the  observer's  ear 
being  practised  in  distinguishing  them.  It  is  therefore  desirable, 
even  for  those  who  are  skilled  in  auscultation  in  general,  to  take 
opportunities  of  practising  this  form  of  it  in  particular.  In  normal 
conditions  the  sounds  are  heard  usually  over  an  area  of  a  circle 
with  a  radius  of  some  5  to  6  cm.,  but  when  they  are  faint  they  are 
audible  only  over  a  very  limited  portion  of  the  abdomen.  If,  there- 
fore, they  are  not  at  first  detected,  the  attempt  should  not  be  given 
up  until  the  whole  surface  of  the  uterus  has  been  explored. 

In  a  few  instances  it  has  been  found  possible  to  palpate  the  foetal 
heart  directly  through  the  abdominal  wall  of  the  mother. 

The  chief  fallacy  which  is  likely  to  occur  is  the  mistaking  the 
woman's  heart-sounds,  which  may  sometimes  be  heard  in  a  similar 
situation,  esj^ecially  when  a  tumour  is  present,  for  those  of  a  foetus. 
If  the  mother's  pulse  is  slow,  while  the  foetal  heart  has  its  usual 
rapidity,  counting  the  two  is  sufficient  to  distinguish  between 
them.  If,  however,  the  woman's  pulse  is  rapid,  120  or  more, 
great  care  is  required.  The  radial  artery  should  be  felt  while 
the  ear  rests  upon  the  stethoscope.  If  the  sounds  heard  are 
really  those  of  a  foetal  heart,  it  will  be  found  that  the  two  will  not 


Diagnosis   of   Pregnancy.  189 

continue  exactly  synchronous  for  long  together,  even  though  their 
rates  are  about  the  same,  but  one  or  the  other  will  fall  behind. 
Another  test,  which  should  be  used  in  addition  in  any  case  of 
doubt,  is  to  trace  the  sounds  towards  the  woman's  heart.  Foetal 
heart-sounds  will  then  be  lost,  but  the  woman's  heart-sounds  will 
become  gradually  intensified. 

Variation  of  Rate  of  Heart  according  to  Sex  and  Size  of  Foetus. — It 
has  been  found  that  the  average  rate  of  heart  is  more  rapid  in 
girls  than  in  boys.  The  average  for  all  children  is  about  132  per 
minute.  If  the  rate  much  exceeds  this,  say  amounts  to  140  or 
more,  there  is  a  certain  presumption  in  favour  of  the  child  being  a 
girl ;  if  it  falls  much  below  it,  say  is  only  124  or  less,  in  favour  of 
its  being  a  boy.  The  observation  is  only  of  value  if  made  before 
labour  has  begun,  in  the  last  two  months  of  pregnancy,  and  while 
the  foetus  is  quiet.  The  rapidity  of  tlie  heart,  however,  varies 
©onsiderably  in  the  same  children  at  different  times  without  any 
obvious  cause,  and  hence  the  method  is  extremely  uncertain. 
Predictions  in  individual  cases  would  not  come  true  in  more  than 
two  cases  out  of  three  at  the  most.  There  have  been  also 
observations  tending  to  show  that  the  rate  of  the  heart  is  slower  the 
larger  the  child ;  and  it  has  been  inferred  by  some  that  boys  have 
slower  pulse-rates  only  because  they  are  generally  larger  than  girls. 
The  fact  that  there  is  no  marked  change  in  the  heart's  rapidity 
from  the  time  when  it  is  first  heard,  when  the  foetus  is  quite  small, 
would  seem  to  be  rather  against  this  view.  At  the  sixteenth  week 
I  have  found  the  rapidity  to  be  not  greater  than  140  per  minute. 

Funic  Souffle. — Occasionally  a  blowing  murmur  is  heard  as 
well  as  the  double  foetal  heart-sound.  Sometimes  this  replaces 
the  foetal  heart- sounds  altogether,  but  more  frequently  the  clear 
heart-sounds  are  heard  at  one  spot,  the  murmur  at  another  not  far 
off.  Such  a  murmur  is  occasionally  a  cardiac  bruit,  but  is  generally 
produced  in  the  funis,  at  some  j)oint  where  it  is  subjected  to 
pressure  or  twisted.  It  is  very  variable  in  the  same  jDcrsons, 
According  to  some,  it  may  be  heard  in  as  many  as  12  or  even 
15  per  cent,  of  cases  at  the  end  of  pregnancy. 

As  the  funic  soufHe  is  produced  usually  by  pressure  on  the  cord 
when  it  persists  throughout  the  whole  course  of  labour,  and 
especially  when  it  increases  in  intensity,  it  forms  an  important 
warning  of  impending  danger  to  the  life  of  the  foetus.  According  to 
Von  Winckel,  some  76'5  per  cent,  of  the  children  are  still-born  in 
these  conditions. 

Special  forms  of  stethoscope  have  been  made  to  auscultate  the 


iQo  The   Practice  of   Midwifery. 

uterus  through  the  vagina ;  and  by  means  of  these,  the  foetal 
movements,  the  uterme  souffle,  and  possibly  the  foetal  heart-sounds, 
may  be  heard  somewhat  earlier.  These  are  not  likely,  however, 
to  come  into  general  use. 

Recapitulation  of  Signs  in  Order  of  Date.— A  brief  re- 
capitulation of  the  more  important  signs  of  pregnancy  in  the  order 
of  their  occurrence  may  here  be  of  use.  Suppression  of  menses 
generally  dates  from  the  commencement.  Pain,  tenderness,  and 
slight  swelling  of  the  breasts  may  begin  from  the  very  first. 
Morning  sickness  may  also  begin  from  the  first,  but  more 
commonly  in  the  second  month.  Within  a  very  few  weeks, 
the  time  varying  according  to  the  skill  of  the  observer,  elastic 
enlargement  of  the  fundus  uteri  may  be  made  out  bimanually, 
and  Hegar's  sign  may  be  distinguished.  From  the  beginning 
of  the  second  month  (in  primiparse)  softening  begins  at  the  tip  of 
the  cervix,  and  gradually  increases.  In  the  second  or  third  month 
some  violet  coloration  of  the  cervix,  as  seen  by  speculum,  may 
commence.  By  the  beginning  of  the  third  month  some  mucoid 
secretion  may  be  squeezed  from  the  breasts.  In  the  third  month 
foetal  movements  may  possibly  be  felt  from  the  vagina  or  bi- 
manually. From  the  beginning  or  middle  of  the  fourth  month 
they  may  be  heard  from  the  abdomen ;  and  from  the  end  of  the 
fourth  month  they  may  also  be  felt  externally.  In  the  fourth 
month  the  changes  of  softening  and  apparent  shortening  in  the 
cervix  are  generally  characteristic,  and  the  cervix  begins  to  ascend 
higher.  Sometimes,  by  the  middle  of  the  fourth  month,  or,  at  any 
rate,  at  the  end  of  it,  ballottement  may  be  obtained.  Towards  the 
end  of  the  fourth  month,  and  sometimes  even  earlier,  the  uterine 
souffle  may  be  heard.  Alternate  contractions  and  relaxations  of  the 
uterus  may  be  made  out  generally  during  the  fifth  month.  The 
foetal  heart  is  generally  first  heard  during  the  fifth  month,  from  the 
eighteenth  to  the  twentieth  week,  but  sometimes  before  the  end  of 
the  fourth  month.  In  the  fifth  month  also,  the  secondary  areola 
sometimes  begins  to  be  visible  round  the  nipples.  From  this  time 
onward  all  the  signs  become  progressively  more  manifest  except 
ballottement,  which  fails  in  the  last  two  or  three  months.  In 
the  last  two  months,  in  multiparge,  the  finger  may  sometimes  be 
passed  through  the  cervix,  and  feel  the  presenting  part. 

Differential  Diagnosis  of  Pregnancy. — A  diagnosis  of 
pregnancy  must  be  based  on  the  recognition  of  the  physical  or 
direct  signs  of  that  state    and  it    is  therefore  unnecessary  to  go 


Diagnosis  of   Pregnancy.  191 

through  all  the  conditions  which  might  possibly  be  mistaken  foi- 
pregnancy,  since  in  all  of  them  these  direct  signs  will  be  absent. 
In  a  case  of  doubt  the  order  of  investigation  should  be  to  ascertain, 
first,  that  some  tumour  is  present  in  the  abdomen ;  secondly,  that 
it  is  the  enlarged  uterus  ;  and  thirdly,  that  the  enlargement  is  due 
to  pregnancy.  It  is  chiefly  within  the  first  four  months,  and 
especially  the  first  three  months,  that  some  uncertainty  may  exist, 
but  a  month  or  two's  delay  will  then  always  solve  the  question. 
Within  the  first  four  months,  the  enlargement  of  the  uterus  due 
to  pregnancy  has  to  be  distinguished  from  that  due  to  fibroid 
tumour  or  subinvolution  and  cbronic  metritis,  and  the  distinction 
may  generally  be  made  by  the  peculiar  elasticity,  and  indefinite 
outline,  so  characteristic  of  the  pregnant  uterus.  It  is  to  be 
remembered,  however,  that  a  dead  ovum  may  be  retained  for 
months  within  the  uterus,  and  that  the  uterus  in  such  a  case  may 
become  hard.  The  nature  of  the  case  will  then  generally  be 
indicated  by  the  history,  especially  by  the  absence  of  menstruation, 
but  sometimes  can  only  be  cleared  up  by  exploration  of  the  cavity 
of  the  uterus.  (See  Chapter  XXII.)  The  tumour  formed  by 
hcematometra,  or  distension  of  the  uterus  with  retained  menstrual 
secretion,  may  resemble  the  pregnant  uterus,  though  generally  it  is 
more  tense.  In  this  case  there  will  be  a  history  of  spasmodic  pain 
recurring  every  month  ;  and  either  the  patient  will  be  a  girl  who 
has  never  menstruated  externally,  or  there  will  have  been  some 
cause,  such  as  an  operation  on  the  cervix,  to  produce  occlusion  of 
that  canal.  Moreover,  the  impervious  state  of  the  vagina  or  cervix 
may  be  detected  on  examination.  The  most  difficult  cases  for 
diagnosis  are  those  in  which  pregnancy  is  comj)licated  with  a 
uterine  or  ovarian  tumour.  In  these  the  tumour  may  obscure  some 
of  the  usual  jjositive  signs  ;  and  not  only  has  the  fact  of  pregnancy 
to  be  made  out,  but  they  have  to  be  distinguished  from  cases  of 
extra-uterine  pregnancy,  which  also  generally  produces  an  irregular 
mass  in  the  abdomen.  In  these  cases  the  likelihood  of  mistaking  a 
retroverted  gravid  uterus  for  a  periuterine  hsematocele  must  be 
borne  in  mind  especially,  and  the  utmost  pains  must  be  taken  to 
ascertain  how  much  of  the  tumour  consists  of  the  uterus,  and 
whether  there  is  a  fcetus  inside  or  outside  the  uterine  cavity.  The 
diagnosis  of  j)regnancy  with  excess  of  liquor  amnii  from  an  ovarian 
cyst,  often  a  difficult  one  to  make,  will  be  considered  under  the 
head  of  hydrops  amnii. 

Pseudocyesis,  or  spurious   Pregnancy.- — A  case    in    which  a 
diagnosis  is  often  called  for,  Ijut  in  which  it  is  not  difficult  to  make, 


192  The   Practice  of   Midwifery. 

if  any  care  is  used,  is  that  of  imaginary  or  spurious  pregnancy,  to 
which  the  term  pseudocyesis  has  been  applied.  En  this  condition 
many  of  the  more  superficial  signs  of  pregnancy  may  exist, 
suppression  of  menstruation,  mammary  changes  with  presence  of 
secretion,  prominence  of  abdomen,  and  supposed  foetal  movements. 
It  may  occur  at  any  time  of  life  in  women  who  desire  or  expect 
that  they  may  become  pregnant.  It  is  most  frequent,  however,  at 
the  approach  of  the  menopause,  when  menstraation  is  arrested,  or 
perhaps  has  only  become  very  scanty,  and  there  is  at  the  same  time 
a  deposit  of  fat  in  the  abdominal  walls  and  flatulent  distension 
of  the  intestines.  The  prominence  of  the  abdomen  may  be  due 
simply  to  these  causes,  but  often  it  is  produced  also  in  part  by  the 
attitude  assumed,  the  convexity  forwards  of  the  lumbar  spine  being 
increased,  and  the  shoulders  thrown  back.  The  mental  condition 
has  much  to  do  with  the  production  of  this  state,  which  is  more 
frequently  found  in  hysterical  women.  It  may  vary  from  a  not 
unnatural  mistake,  dispelled  at  once  by  a  medical  opinion,  through 
all  degrees  up  to  an  almost  insane  delusion,  proof  against  assurances, 
which  may  persist  for  more  than  the  natural  nine  months  of  preg- 
nancy. In  more  rare  cases,  in  addition  to  the  spurious  pregnancy, 
there  is  a  spurious  labour  when  the  expected  time  of  delivery  has 
arrived,  and  labour  pains  seem  to  come  on,  and  recur  for  some  time 
at  regular  intervals.  This  generally  happens  to  a  woman  whose 
medical  attendant  has  accepted  her  own  account  of  her  condition 
without  investigation. 

Spurious  pregnancy  is  easily  recognised  on  examination.  There 
is  no  complete  dulness  in  the  abdomen,  though  there  may  be 
diminished  resonance  from  deposit  of  fat.  The  os  is  found  unaltered, 
and  there  is  no  uterine  tumour  to  be  felt  on  bimanual  examination. 
The  apparent  tumour  produced  by  arching  of  the  spine  and  tension 
of  the  muscles  is,  if  necessary,  dispelled  at  once  on  the  adminis- 
tration of  an  anesthetic.  The  formality  of  this  proceeding,  coupled 
with  a  consultation,  is  often  of  great  use  in  convincing  the  patient, 
or  at  any  rate  her  friends,  that  no  pregnancy  exists. 

Diagnosis  of  the  Life  or  Death  of  the  Fcetus. — The  indications 
of  the  life  of  the  fcetus  to  be  relied  on  are  the  fcetal  heart-sounds 
and  fcetal  movements.  If,  after  being  manifest,  these  can  no 
longer  be  discovered  on  repeated  examinations  by  a  competent 
person,  its  death  may  be  inferred.  Some  weight,  but  not  an  abso- 
lute one,  may  be  attached  to  the  sensation  of  movements  by  the 
mother.  In  the  earlier  months  of  pregnancy,  before  movements  or 
heart-sounds  are  distinguishable,  the  foetus  may  be  inferred  to  be 


Diagnosis  of   Pregnancy.  193 

dead  if  the  enlargement  of  the  uterus  be  observed  to  have  become 
arrested,  and  there  has  been  a  recession  in  the  development  of  the 
breasts.  Sometimes,  but  not  always,  the  mother's  health  becomes 
impaired  in  such  a  case.  In  some  cases,  especially  when  at  least 
the  half-term  of  pregnancy  has  been  reached,  the  death  of  the 
foetus  j)roduces  an  increased  secretion  of  colostrum  or  milk,  similar 
to  that  which  occurs  after  its  expulsion.  This  is  shortly  followed 
by  recession  of  the  breasts.  Generally,  after  death  of  the  ovum, 
reflex  symptoms  of  pregnancy,  such  as  vomiting,  diminish  or 
disappear.  But,  in  some  instances,  vomiting  and  general  malaise 
commence  only  on  the  death  of  the  ovum.  A  sense  of  coldness  in 
the  situation  of  the  uterus  is  given  as  a  sign  of  death  of  the  ovum, 
but  is  not  much  to  be  relied  upon.  The  dead  ovum  cannot  of 
course  become  colder  than  the  maternal  tissues  surrounding  it, 
although  it  ceases  to  impart  warmth  to  them. 

It  has  been  suggested  to  place  a  thermometer  in  the  vagina  and 
then  in  the  cervix,  and  if  the  temperature  of  the  two  cavities  is 
found  to  be  the  same,  there  is  a  considerable  probability  that  the 
foetus  is  dead. 

Considerable  and  persistent  haemorrhage  from  the  uterus  does 
not  necessarily  imply  the  death  of  the  foetus ;  an  offensive 
uterine  discharge  generally  does  so.  If  the  finger  can  be  passed 
through  the  os,  and  feel  the  cranial  bones  loosened  in  the  scalp,  the 
death  of  the  foetus  is  assured. 

Diagnosis    between    first    and    subsequent  Pregnancies. — 

The  most  valuable  distinction  between  first  and  subsequent  preg- 
nancies is  to  be  found  in  the  condition  of  the  hymen.  The  effect 
of  coitus  is  generally  to  tear  notches  in  the  edge  of  the  hymen. 
These  do  not,  however,  extend  completely  down  to  the  base  of 
attachment  of  the  hymen,  which  forms  the  lower  limit  of  the 
vagina.  In  a  nulliparous  woman,  therefore,  the  hymen  can  always 
be  easily  traced,  its  attachment  being  continuous,  its  free  border 
more  or  less  broken  up.  If  the  two  index  fingers  be  inserted 
between  the  hymen  and  the  fourchette,  and  separated  a  little 
laterally,  the  fossa  navicularis,  or  boat-shaped  depression  thus 
produced,  can  be  made  out.  On  the  other  hand,  the  effect  of 
parturition  in  a  primipara,  either  at  full  term,  or  in  the  later  months 
of  pregnancy,  is  to  produce  an  inevitable  laceration  of  the  vaginal 
outlet,  formed  by  the  hymeneal  attachment,  this  being  the  narrowest 
and  least  dilatable  part  of  the  canal  formed  by  the  soft  parts.  The 
laceration  consists  of  one,  or  more  frequently  several,  longitudinal 
rents,  extending  completely  to  the  base  of  the  hymeneal  attachment 
M.  13 


194  The  Practice  of   Midwifery. 

and  separating  the  component  parts  of  the  hymen.  In  a  parous^ 
woman,  therefore,  the  hymen  either  remains  only  in  the  form  of 
several  detached  prominences  of  mucous  membrane,  the  caruncidce 
myrtiformes,  or,  at  any  rate,  there  are  one  or  more  well-marked 
spaces,  or  cicatricial  bands  separating  its  torn  fragments.  The  fossa 
navicularis  no  longer  exists  as  a  depression  ;  but  the  mucous  mem- 
brane forming  it  has  become  flush  with  the  posterior  vaginal  wall. 
The  essential  part  of  the  process  concerned  in  the  production  of 
carunculffi  myrtiformes  is  the  sloughing  of  intermediate  portions  of 
hymen,  which  only  occurs  after  the  bruising  of  labour.  The  only 
thing  which  could  possibly  simulate  the  effects  of  labour  is  the 
delivery  of  a  large  tumour  through  the  vagina. 

There  are  many  other  signs  whose  presence  affords  more  or  less 
positive  evidence  of  a  previous  pregnancy,  though  their  absence 
does  not  prove  that  a  former  parturition  may  not  have  occurred, 
especially  at  an  interval  of  a  considerable  number  of  years,  or  before 
the  full  term  of  pregnancy.  The  most  decisive  of  these  are  the 
existence  of  old  lacerations  of  the  perineum,  either  destroying  the 
fourchette  only  or  extending  more  deeply,  and  alterations  in  the 
cervix.  Generally  in  parous  women  the  os  uteri  is  converted  from 
a  round  or  oval  opening  into  a  transverse  slit,  from  slight  notches 
at  each  side  having  been  produced  by  laceration  in  parturition ; 
and  from  the  same  cause  the  cervix  becomes  broader  at  the  end  and 
less  tapering.  It  also  softens  less  early  in  a  subsequent  pregnancy. 
Not  infrequently  there  is  more  obvious  evidence  of  previous 
parturition  in  the  presence  of  the  deeper  lacerations  produced 
in  labour.  These  are  most  frequently  bilateral,  usually  deepest 
on  the  left  side,  and  they  are  often  accompanied  by  eversion 
of  the  anterior  and  posterior  lips  of  the  cervix.  Sometimes 
they  are  unilateral,  triradiate,  or  still  more  irregular.  Other 
signs  are  the  result  of  distension  in  previous  pregnancies.  The 
abdominal  walls,  instead  of  being  tense,  are  often  lax,  so  that 
they  can  be  raised  in  a  fold  between  the  fingers,  and  allow  the 
uterus  and  parts  of  the  foetus  to  be  more  readily  explored.  The 
breasts  are  flaccid  and  drooping  instead  of  being  firm  and  tense. 
Besides  the  reddish  or  bluish  skin-cracks  on  the  side  of  the  abdo- 
men and  the  breasts,  which  appear  only  in  the  later  months  of 
pregnancy  under  the  influence  of  actual  tension,  other  old,  silvery 
white  skin-cracks  {linece  albicantes)  may  be  detected,  before  the  skin 
is  actually  put  on  the  stretch. 

^  I.e.,  a  woman  who  has  borne  one  or  more  children. 


Chapter   X, 
THE  DURATION   AND  HYGIENE  OF  PREGNANCY. 

The  Duration  of  Pregnancy. — It  is  never  possil)le,  in  the  human 
subject,  to  determine  the  exact  date  of  conception.  It  is  only  in 
very  exceptional  cases  that  the  date  of  fruitful  coitus  is  known,  and 
even  when  this  is  the  case,  it  is  possible  that  conception  may  not 
occur  for  several  days,  possibly  even  as  much  as  ten  or  fourteen 
days  afterwards,  the  spermatozoa  meanwhile  retaining  their 
vitality.  In  general,  the  only  date  we  have  to  reckon  from  is  that 
of  the  last  menstruation,  and  this  is  sufl&ciently  accurate  for  most 
purposes,  since,  as  we  have  already  mentioned,  the  most  favourable 
time  for  impregnation  is  when  menstruation  and  ovulation  coincide, 
and  insemination  occurs  just  before  or  after  menstruation. 

In  the  case  of  domestic  animals,  where  there  is  generally  only  a 
single  coitus,  and  that  at  a  period  of  ovulation,  more  exact  obser- 
vations are  possible.  The  result  is  to  show  that  there  are  con- 
siderable variations  in  the  duration  of  pregnancy  dating  from  the 
coitus,  greater  even  than  are  supposed  to  occur  in  the  case  of 
women.  Not  only  do  some  deliveries  occur  considerably  before 
the  average  date  at  which  the  great  majority  take  place,  a  result 
which  might  be  due  to  premature  labour,  but  a  few  occur  con- 
siderably after  it,  and  thus  appear  to  prove  an  unusual  protraction 
of  gestation  in  some  individual  cases.  Thus  in  cows  the  average 
duration  of  pregnancy  is  about  282  days.  Oat  of  140  cows  observed 
by  Tessier,  121  calved  between  the  269th  and  290th  day,  but  five 
calved  between  the  290th  and  308th  day.  Again,  in  mares  the 
average  duration  is  about  348  days.  Out  of  102  mares  observed  by 
Lord  Spencer,  72  foaled  between  the  340th  and  360th  day,  but  21 
foaled  at  various  times  from  the  360th  to  the  377  th  day,  and 
one  on  the  394th  day.  From  analogy  it  may  be  expected,  that,  in 
the  human  subject  also,  pregnancy  may  in  exceptional  cases  be 
protracted  longer  than  usual,  and  the  child  probably  in  consequence 
attain  an  unusual  size. 

The  calculation  of  the  average  duration  of  pregnancy  from  a 
single  coitus  is  open  to  considerable  uncertainty,  since  many  of  the 
cases  are  those  of  unmarried  women  whose  statements  on  the 
subject    are    open    to    suspicion.      Matthews    Duncan    collected 

13—2 


196  The   Practice  of   Midwifery. 

46  cases,  and  calculated  an  average  of  275  days.  Other  authors 
give  other  estimates,  generally  lower  than  this,  and  varying  from 
268  to  276  days.^  The  question  of  the  duration  of  pregnancy  from 
the  fertile  coitus  is  chiefly  of  interest  in  reference  to  the  medico- 
legal question,  whether  a  child  is  to  be  regarded  as  possibly 
legitimate  or  not,  when  born  at  an  interval  longer  than  usual  after 
the  last  possible  date  of  coitus  with  the  husband.  The  laws  of 
Scotland,  France,  and  Austria,  allow  a  possible  limit  of  300  days, 
that  of  Prussia  one  of  302  days.  In  England  and  America  no 
absolute  limit  is  laid  down,  but  each  case  must  be  judged  on  its 
merits.  In  America  a  very  liberal  view  has  been  taken,  and 
legitimacy  has  been  allowed  after  intervals  of  313  and  317  days. 
No  case  of  protraction  beyond  300  days  from  a  single  known  coitus 
has,  however,  been  scientifically  established.  Of  James  Eeid's  cases 
the  longest  was  293,  and  Leishman  relates  the  case  of  a  married 
lady,  in  which  the  interval  was  295  days,  and  the  child  weighed 
12  lb.  3  oz.  Of  cases  in  which  the  minimum  duration  of  pregnancy 
was  supposed  to  be  fixed  by  the  death  or  departure  of  the  husband, 
one  recorded  by  Mr.  Hewitt  gives  308  days,  one  by  Sir  James 
Simpson  313  days,  and  two  by  Dr.  Murphy  314  and  324  days 
respectively.  The  last,  at  least,  is  reasonably  open  to  doubt,  but 
there  is  some  reason  to  think  that  pregnancy  may  possibly  be 
sometimes  prolonged  to  the  equivalent  of  ten  menstrual  periods 
instead  of  nine,  or  to  about  308  days.  For  cases  have  been 
recorded  in  which  labour  pains  have  come  on  at  the  expected  time, 
but  have  passed  off  again,  and  have  not  recurred  until  four  weeks 
later,  while  the  child,  when  born,  has  been  of  unusual  size  and 
weight.  In  any  medico-legal  case,  the  fact  of  a  child  having  been 
of  unusual  size  at  birth  would  be  evidence  in  favour  of  the  possi- 
bility of  the  pregnancy  having  been  unusually  protracted,  although 
it  is  also  possible  that  the  child  might  be  unusually  small  at  full 
term,  and  therefore  not  larger  than  usual  when  born  at  a  later 
period.  Ballantyne  records  the  case  of  an  anencephalic  foetus, 
which  must  have  been  either  1^  or  2^  months  post-mature,  and 
which  weighed  9  lb.  although  anencephalic,  and  showed  other 
signs  of  post-maturity  ;  ^  that  is,  it  was  not  only  large,  but  apart 
from  the  deformity  exceptionally  well  developed. 

1  See  Montgomery,  Signs  of  Pregnancy,  2ncl  ed.,  pp.  493  et  seq.  ;  Duncan, 
Fecundity,  Fertility,  and  Sterility,  1871,  p.  457;  Ahlfeld,  "  Beobachtungen  liber  die 
Dauer  der  Schwangerschaft,"  Mon.  f.  Geb.,  1869,  XXXIV.;  Lowenhardt,  "Die 
Berechnung  und  die  Dauer  der  Schwangerschaft,"  Arch.  f.  Gyn.,  1872,  III.  ; 
V.  Winckel,  Samml.  Klin.  Vortr.,  N.  F.,  No.  285,  1900,  Gyniik.  No.  84;  Issmer, 
Archiv.  f.  Gynak.,  1887,  Hft.  2,  XXX.,  p.  277,  1889,  Hft.  2,  XXXV.,  p.  310;  Filth, 
Zentrbl.  f.  Gynak.,  1902,  No.  39. 

2  Journ.  of  Obst.  and  Gyn.  Brit.  Emp.,  Dec,  1902. 


The  Duration  and   Hygiene  of   Pregnancy.      197 

The  actual  duration  of  pregnancy  is  dependent  upon  a  number 
of  different  factors,  such  as  the  sex  and  size  of  the  child,  the  con- 
stitution and  strength  of  the  mother,  whether  she  is  a  married  or  a 
single  woman,  the  number  of  pregnancies  she  has  had,  and  the 
amount  of  rest  she  is  able  to  take  during  the  latter  months  of  her 
pregnancy. 

As  a  general  rule,  when  the  size  of  the  child  exceeds  the  normal, 
the  duration  of  the  pregnancy  does  so  also.  Thus  the  average 
length  of  the  pregnancy  for  children  weighing  more  than  4,000 
grammes,  or  8*8  lb.,  is  286  days  counting  from  the  last  menstrual 
period,  and  275  days  reckoning  from  a  single  coitus.  Of  245  such 
children,  in  12"2  per  cent,  the  pregnancy  lasted  more  than  302 
days  from  the  last  menstrual  period,  and  in  4  of  118  more 
than  302  days  from  a  single  coitus.  At  the  same  time  it  must 
be  remembered  that  pregnancy  may  be  prolonged  with  a  child  of 
average  size.  Thus  in  3'2  per  cent,  of  children  weighing  less 
than  4,000  grammes,  or  8*8  lb.,  the  pregnancy  lasted  more  than 
302  days. 

Cases  are  recorded  of  very  considerable  apparent  protraction  of 
pregnancy  from  the  date  of  the  last  menstrual  period.  It  is  not 
wonderful  that  this  should  be  the  case,  since  it  is  an  undoubted 
fact  that  conception  may  occur  during  a  period  of  amenorrboea, 
and  such  cases  prove  nothing  as  to  real  prolongation  of  gestation. 
It  is  possible  that  cases  of  apparent  protraction  for  two  or  three 
weeks  may  dei)end  upon  conception  having  occurred  just  before  the 
first  menstrual  period  which  failed  to  appear.  The  following  table 
gives  the  result  of  650  cases  in  which  the  foetus  was  apparently 
mature,  observed  by  Merriman  and  James  Eeid,  the  duration  being 
calculated  from  the  last  day  of  menstruation  : — 

28  were  delivered  in  the  37th  week — 253  to  259  days. 


64 

38th  , 

260  to  266  „ 

102 

39th  , 

267  to  273  „ 

177 

40th  , 

274  to  280  „ 

140 

41st  , 

281  to  287  „ 

81 

42nd  , 

288  to  294  „ 

39 

43rd  , 

295  to  301  „ 

13 

44th  , 

302  to  308  „ 

6 

45th  , 

309  to  315  „ 

Calculation  of  probable  Date  of  Delivery. — The  most  con- 
venient practical  rule  for  calculating  the  date  of  delivery  is  based 
upon  the  fact  that  278  days  is  the  average  time  from  the  termination 
of  the  last  menstrual  period,  taking  the  mean  of  the  observations 


198 


The  Practice  of   Midwifery. 


of  different  authors.   Hence  we  get  the  following  table  for  calculating 
the  date  of  delivery  : — 


days. 


Average  duration,  278  days. 

From  Jan. 

1  to  Oct.     1 

=  273  (274)  days— Add  5  (4) 

„     Feb. 

1  to  Nov.   1 

=  273  (274) 

,     5(4) 

,     Mar. 

1  to  Dec.    1 

=  275 

„     3 

,     Apr. 

1  to  Jan.    1 

=  275 

,     3 

,     May 

1  to  Feb.    1 

=  276 

,     2 

,      June 

1  to  Mar.  1 

=  273  (274) 

!>                      ! 

,     5  (4) 

,     July 

1  to  Apr.    1 

=  274  (275) 

,     4  (3) 

,     Aug. 

1  to  May   1 

=  273  (274) 

,     5  (4) 

,     Sept. 

1  to  June  1 

=  273  (274) 

,     5  (4) 

,     Oct. 

1  to  July    1 

=  273  (274) 

,     5(4) 

,     Nov. 

1  to  Aug.   1 

=  273  (274) 

„     5  (4) 

,     Dec. 

1  to  Sept.  1 

=  274  (275) 

,     4(3) 

In  the  above  table  the  figures  in  brackets  are  to  be  used  in  leap- 
year  in  place  of  the  others.  The  mode  of  using  it  may  be  explained 
by  examples.  Suppose  the  last  menstrual  period  ended  on  Jan.  10, 
then  Oct.  10  will  be  273  days  (or  in  leap  year  274  days)  ;  add  5 
days  (or  in  leap-year  4  days)  to  make  up  the  average  interval  of 
278  days ;  this  will  give  Oct.  15  as  the  most  probable  date  for 
delivery,  which  is  likely  to  take  place  within  about  a  week  on  one 
side  or  the  other  of  that  date.  Again,  suppose  the  last  menstrual 
period  ended  on  March  29,  then  Dec.  29  will  be  275  days ;  add  3 
days  to  make  up  the  average  interval  of  278  days,  this  will  give 
Jan.  1  as  the  most  probable  date  for  delivery. 

The  following  rule,  which  may  be  easily  remembered,  will  give 
the  same  results  as  the  above  table  within  one  day,  which  is  a 
difference  of  little  consequence,  where  exact  determination  is 
impossible.  Take  the  date  of  the  end  of  last  menstruation  ;  from 
this  reckon  nine  calendar  months  forward,  or  what  is  equivalent  to 
the  same  thing,  three  months  back  ;  if  the  end  of  February  is 
included  in  the  nine  months  add  5  days  (in  leap-year  4  days),  if 
not,  add  3  days.  Thus,  suppose  Feb.  10  the  last  day  of  menstrua- 
tion ;  reckon  nine  months  forward  to  Nov.  10,  and  add  5  days, 
this  will  give  Nov.  15  as  the  most  probable  date  of  delivery.  This 
rule  is  exactly  correct  for  nine  months  out  of  the  twelve ;  for  the 
remaining  three  it  gives  an  error  of  only  one  day.  If  it  be  pre- 
ferred to  reckon  from  the  first  day  of  menstruation  instead  of  the 
last,  or  if  the  record  of  the  former  day  only  be  preserved,  the 
average  duration  may  be  reckoned  at  282  days  instead  of  278,  and 
the  same  rule  applied,  with  the  addition  of  four  days  extra. 


The  Duration  and   Hygiene  of   Pregnancy.      199 

In  confirmation  of  the  calculation  derived  from  the  date  of  last 
menstruation,  the  date  of  quickening,  which  is  on  the  average  at 
about  the  seventeenth  week  in  a  multipara,  although  it  may  not 
occur  until  the  twentieth  week  in  a  primipara,  may  be  inquired  for, 
but  it  varies  so  much  in  different  women  that  no  very  positive 
inference  can  be  deduced  from  it.  Still,  it  is  valuable  as  a  confirma- 
tion, if  it  agrees  with  the  result  obtained  from  the  date  of  last 
menstruation,  while,  if  there  is  a  very  wide  discrepancy,  this  may 
lead  to  the  detection  of  cases  in  which  either  there  is  menstruation 


Fia.  125. — Mode   of   measuring  the  height  of   the  fundus  uteri  above  the 
symphysis  pubes  with  callipers. 


for  a  period  or  two  after  conception,  or  in  which  conception  occurs 
during  a  period  of  amenorrhoea.  If,  therefore,  the  date  of  quickening 
is  very  widely  apart  from  what  is  supposed  to  be  the  seventeenth 
week,  it  is  well  to  estimate  the  size  of  the  uterus  by  abdominal 
examination.  This  should  be  done  in  any  case  where  it  is  of 
importance  to  have  a  correct  estimate  of  the  date  of  pregnancy,  as 
when  premature  labour  is  to  be  induced  in  cases  of  pelvic  contrac- 
tion. The  position  of  the  fundus  uteri  at  the  several  months  has 
been  already  described  (see  p.  153).  The  estimate  may  be  made 
best  in  the  middle  months  of  pregnancy,  from  the  fourth  to  the 
seventh,  and  it  must  Ije  remembered  that  the  height  generally 
assigned  to  the  fundus  uteri  at  the  fifth  and  sixth  months  is  too 


200  The  Practice   of   Midwifery. 

low,  and  that  the  fundus  generally  reaches  the  level  of  the  umbilicus 
at  the  end  of  the  twentieth  week  or  soon  after.  The  distance  of  the 
umbilicus  from  the  pelvis,  however,  varies  in  different  cases,  and 
there  are  two  methods  which  give  a  more  accurate  result,  the  first 
that  of  measuring  the  height  of  the  fundus  uteri  above  the  pubes ; 
the  second  that  of  measuring  the  length  of  the  foetus  itself,  as  it  lies 
within  the  uterus.  For  the  first  method,  the  position  of  the  fundus 
is  made  out  by  palpation  and  percussion,  and  the  distance  from  the 
point  so  determined  to  the  pubes  is  measured  by  callipers  (Fig.  125). 
In  order  to  ascertain  the  length  of  the  foetus  i)i  utero,  one  arm  of 
the  callipers  is  introduced  into  the  vagina,  and  placed  upon  the 
lowest  point  of  the  head,  the  uterine  wall  intervening  ;  the  other 
arm  is  placed  on  the  outside  of  the  abdomen  on  the  highest  part  of 
the  breech. 

For  results  of  value  to  be  obtained  from  the  method  of  estimating 
the  height  of  the  fundus  uteri,  it  is  necessary  to  take  into  account 
the  size  and  attitude  of  the  child,  the  amount  of  liquor  amnii,  the 
thickness  of  the  abdominal  wall,  and  the  degree  of  engagement  of 
the  head  in  the  pelvic  brim.  The  other  method  is  available  when- 
ever the  long  axis  of  the  foetus  can  be  brought  into  such  a  position 
that  it  can  be  measured  by  the  callij)ers. 

Height  of  fundus        Length  of  foetus        Height  of  fundus  circumference 

Week  of               uteri  above  pubes  nieasured  iu           uten  above  pubes        of  the  abdomen 

pregnancy.                  measured  by  ^                          measured  by                (Schrader). 

callipers.  i^tru.                tape  (Spiegelberg).           *■                ' 

ins.    cm.  ins.    cm.                    ins.      cm.                    ins.       cm. 

40     10=2.5  9i  =  24-5  13i  =  23        40=100 

38    92  =  24  93  =  24  13  =22-5 

36    9i  =  23  9i  =  23  123  =  21-5     39*=   99 

34    9''  =  225  8|  =  22  12=20 

32    83  =  21-5  8i=20o  11|  =  19        38*=   97 

30    8|  =  20-5  8=20  11  =17-5 

28    74=19-5  73=19  10?  =  16-5     373=  94 

26    7^  =  18  7|  =  18  I 

24    63=16-5  —                     [       10-5 


22  6  =15        —  ) 

20  08=13-5 

18  43=11-5 

16  4"  =  10 

The  figures  in  the  first  two  columns  of  the  table  are  mainly 
taken  from  those  of  Sutugin/  which  do  not  differ  greatly  from 
the  results  obtained  by  Ahlfeld.^  The  height  of  the  fundus  uteri 
above  the  pubes  may  also  be  estimated  by  a  tape  measure ; 
but  this  does  not  give  so  accurate  a  result  as  measurement  by 
callipers.      The    average   measurements    taken    by   this   method, 

^  "  On  the  Means  of  ascertaining  the  Length  of  Gestation,"  &c.,  Obstet.  Journ.  of 
Great  Britain  and  Ireland,  1875,  Vol.  Ill 

2  "  Bestimmungen  der  Grosse  und  des  Alters  der  Frucht,"  Arcli.  fiir  Gynak.,  Bd.  2, 
p.  252. 


The  Duration  and   Hygiene  of   Pregnancy.     201 

according  to  Spiegelberg,^  are  given  in  the  third  column  of  the 
table.  The  figures  in  the  lower  part  of  the  first  column,  from  the 
twenty-sixth  to  the  sixteenth  week,  are  based  upon  my  own  observa- 
tion, the  averages  given  by  Sutugin  being  taken  from  only  one  or 
two  cases.  The  measurement  of  the  circumference  of  the  abdo- 
men is  also  of  some  value  in  determining  the  duration  of  pregnancy. 
According  to  all  three  authors,  the  height  of  the  fundus,  in  the 
horizontal  position  of  the  woman,  continues  to  increase  progressively 
even  in  the  last  few  weeks  of  pregnancy,  and  the  sinking  of  the 
fundus  in  the  last  two  or  three  weeks,  so  often  spoken  of,  exists 
only  in  the  standing  position.  The  method  of  measuring  the  foetus 
itself,  instead  of  the  height  of  the  fundus,  is  preferable,  especially 
in  cases  of  pelvic  contraction,  when  the  foetal  head  cannot  descend 
into  the  pelvis,  and  the  fundus  is  therefore  unduly  elevated.^ 

Hygiene  of  Pregnancy. — Pregnancy  being  a  natural  physiolo- 
gical condition,  the  ordinary  mode  of  life,  provided  it  is  a  healthy  one, 
should  not  be  too  much  departed  from.  In  normal  circumstances, 
an  increased  supply  of  nourishing  food  is  generally  required,  but  it 
should  be  given  in  the  most  digestible  form,  and  the  patient  should 
be  warned  against  an  excess  of  meat  in  the  diet.  It  is  of  great 
importance  to  keep  up  a  reasonable  amount  of  exercise  in  the  open 
air,  to  preserve  the  muscular  system  in  good  tone.  Women  of  the 
labouring  class,  who  work  in  the  open  air  throughout  pregnancy, 
pass  through  their  confinements  with  much  greater  ease  than  those 
who  lead  sedentary  lives.  It  is  reasonable  to  expect  that  women 
who  spend  a  great  part  of  the  day  in  bed,  or  on  a  sofa,  will  be 
ill  prepared  for  the  severe  muscular  effort  required  in  labour.  On 
the  other  hand,  excessive  fatigue,  strains,  and  the  lifting  or  carrying 
heavy  weights  are  to  be  avoided.  Women  should  be  protected  as 
far  as  possible  from  any  fright,  mental  shock,  mental  distress,  or 
undue  excitement.  Constipation  is  to  be  guarded  against  by  diet 
as  far  as  possible,  but  violent  purgatives  should  be  avoided.  Baths 
may  be  used  according  to  the  ordinary  custom,  and  the  genitals 
should  be  frequently  washed  with  warm  water ;  but  some  degree  of 
caution  is  required  as  to  vaginal  injections.  They  may  be  used  if 
there  is  leucorrhoea,  but  they  should  neither  be  very  hot  nor  very 

^  Lchrbuch  der  Geburtshiilfe,  2nd  ed.,  p.  111. 

'^  Ahlfeld  gives  the  following  useful  formula  for  determining  the  age  of  the  foetus 

from   its  length  in  utero  : — ^= ^—^ =  age  in  months  and  weeks,  a  being  the 

(22    X   2)  -  2        42  _, 

lengLli  of  the  ffjetus  in  uteru   in  centimetres;  thus    p = -g- =:  8|,  or  q^ 

months. 


202  The  Practice  of   Midwifery. 

cold,  and  the  injection  should  not  be  made  with  much  force.  It  is 
not  usual  to  abstain  from  marital  intercourse  during  pregnancy, 
although  in  this  respect  the  lower  animals  set  an  example  to  the 
human  race.  Coitus  is,  however,  a  frequent  cause  of  abortion,  and 
much  moderation  is  desirable,  especially  during  the  first  four 
months.  If  a  woman  has  aborted  before,  or  if  there  are  symptoms 
of  threatened  abortion,  abstinence  during  at  least  the  earlier  part 
of  pregnancy  should  be  advised. 

The  dress  should  be  such  as  to  avoid  all  undue  pressure.  Garters 
should  be  discarded,  as  tending  to  promote  varicose  dilatation  of  the 
veins.  Stays,  if  worn,  should  be  made  to  expand.  It  is  better, 
however,  to  use  no  stays,  but  have  each  skirt  of  petticoat  or  dress 
attached  to  a  bodice,  so  as  to  hang  from  the  shoulders.  In  multi- 
parse,  if  there  is  a  jDendulous  abdomen,  from  laxity  of  the  abdominal 
walls,  involving  a  tendency  to  anteversion  of  the  uterus,  an 
abdominal  belt  should  be  worn.  Great  care  should  be  taken  that 
the  stays  do  not  press  upon  the  nipples  and  flatten  them.  If  the 
nipples  are  already  flattened,  a  guard  may  be  worn  over  them,  and 
this  may  tend  to  promote  their  development,  but  they  should  not 
be  actively  drawn  out.  The  nipples  may  be  prepared  for  lactation 
by  anointing  them  each  night  with  some  pure  lanoline  and  washing 
them  daily  with  spirit  and  water,  or  with  a  solution  of  boric  acid  in 
50  per  cent,  alcohol.  This  care  is  especially  desirable  in  primiparae, 
or  if  there  have  been  sore  nipples  in  a  previous  lactation. 

The  special  disorders  of  pregnancy  will  be  considered  hereafter. 
The  general  principle  is  to  exhort  women  to  endure  the  minor 
inconveniences  as  unavoidable  for  the  time,  and  specially  to  avoid 
any  unnecessary  activity  in  treatment. 

It  is  advisable  to  test  the  urine  for  albumen  from  time  to  time, 
say  once  a  month  in  the  earlier  months,  and  once  a  week  in  the  last 
two  months  of  pregnancy. 

It  is  also  advisable  to  make  a  preliminary  abdominal  examination 
at  least  a  month  before  full  term,  in  order  to  estimate  the  position 
and  size  of  the  foetus,  and  the  dimensions  of  the  pelvis.  External 
pelvic  measurements  should  be  taken,  if  not  already  known  ;  but  it 
is  only  exceptionally  necessary  to  make  a  vaginal  examination. 

If  any  vaginal  examination  is  made  within  the  last  month  of 
pregnancy,  antiseptic  precautions  should  be  observed  as  carefully  as 
at  the  time  of  labour.  Coitus  during  the  last  month  should  be 
discouraged.  Puerperal  septicaemia  has  been  attributed  to  contagion 
conveyed  in  this  way  to  the  vagina. 


Chapter  XI, 
LABOUR. 

Labour  has  to  be  regarded  in  two  aspects,  first  as  a  series  of 
vital  actions  to  effect  delivery^  secondly  as  a  mechanical  process, 
the  course  of  which  depends  upon  the  motor  forces  which  act,  and 
the  resistances  which  are  called  into  play  by  the  relations  of  the 
passenger  to  the  passages  through  which  it  has  to  pass.  The 
physiological  and  clinical  ]3henomena  of  labour  will  here  be  first 
considered. 

Causes  which  determine  Labour. — The  reason  why  labour 
comes  on  so  regularly  at  a  definite  time  is  not  fully  understood. 
Among  the  more  important  of  the  causes  which  have  been  assigned 
for  its  occurrence  are  the  following  : — 

(1)  Increased  irritability  of  the  uterine  muscle ; 

(2)  The  increased  growth  of  the  ovum  ; 

(3)  The  occurrence  of  coagulation  necrosis  in  the  cells  of  the 
decidua  and  in  the  epithelium  of  the  chorionic  villi ; 

(4)  The  occurrence  of  thrombosis  in  the  veins  of  the  placental 
sinuses  ; 

(5)  Increased  venosity  of  the  foetal  blood  and  a  deficiency  of 
oxygen  in  the  utero-placental  vessels  ; 

(6)  The  accumulation  of  toxic  materials  derived  from  the  foetus 
in  the  mother's  blood  ; 

(7)  Alterations  in  the  maternal  metabolism  associated  with  the 
menstrual  periodicity  and  attaining  their  maximum  at  the  end  of 
pregnancy  ; 

(8)  Gradual  diminution  of  the  power  of  the  growing  ovum  to 
exert  an  inhibitory  action  upon  the  uterine  contractions ; 

The  irritability  of  the  uterus,  no  doubt,  increases  progressively 
throughout  pregnancy,  and  it  is  thought  that,  although  ovulation 
is  suspended,  the  menstrual  nisus  does  to  some  extent  continue, 
and  that  the  uterine  contractions  which  are  periodically  taking 
place  become  more  active  at  the  times  when  menstruation  would 
have  occurred.  Accordingly  abortion  or  miscarriage  is  more  likely  to 
occur  at  such  a  time.  It  is  only  necessary  for  the  ordinary  uterine 
contractions  to  be  intensified  up  to  the  point  at  which  they  begin 


204  The   Practice  of   Midwifery. 

to  cause  some  dilatation  of  the  internal  os  and  pressure  of  the 
membranes  against  it ;  and  then  the  reflex  mechanism  is  started  by 
which  the  process  of  labour  thenceforth  goes  on  automatically.  It 
appears  that  the  uterine  irritability  and  the  stimulus  reach  a 
sufficient  intensity  to  bring  this  about  generally  at  the  time  when 
the  tenth  menstrual  period  would  have  occurred.  It  remains,  how- 
ever, to  explain  why  this  should  happen  at  the  tenth  menstrual 
period  and  not  at  any  other.  It  cannot  be  due  simply  to  the 
magnitude  of  the  uterine  contents  having  reached  a  certain  point, 
for,  when  there  is  an  excessive  secretion  of  liquor  amnii,  a  more 
extreme  distension  may  be  produced  in  the  earlier  months  of 
pregnancy  without  bringing  on  labour.  In  many  cases  of  twin 
pregnancy,  also,  any  given  degree  of  uterine  distension  would  be 
reached  at  an  earlier  stage. 

In  connection  with  the  explanation  of  the  onset  of  labour,  the 
following  facts  have  also  to  be  explained  :  (1)  In  extra-uterine 
foetation,  if  the  foetus  lives  up  to  the  end  of  the  ninth  month,  there 
is  a  kind  of  false  labour  at  that  time,  a  decidual  membrane  is 
expelled  from  the  uterus,  and  the  foetus  dies  about  the  same  time. 
(2)  When  one  fcetus  dies  in  the  case  of  twins  it  is  frequently  retained 
within  the  uterus  until  the  other  has  reached  maturity,  and  is  then 
expelled  with  it.  (3)  An  ovum  sometimes  perishes  in  the  earlier 
part  of  pregnancy,  but  is  retained  within  the  uterus  for  months, 
and  sometimes  is  only  expelled  at  the  end  of  the  ninth  month.  One 
of  the  most  important  theories  is  that  originally  proposed  by  Sir 
James  Simpson,  that  when  the  fcetus  approaches  maturity,  a 
change,  namely,  fatty  degeneration,  as  he  thought,  takes  place  in 
the  decidua,  preparing  it  for  separation  from  the  uterus,  and  some- 
what analogous  to  the  change  in  the  stalk  of  a  fruit,  causing  its 
separation  from  the  tree  when  the  fruit  is  ripe.  In  consequence  of 
the  coagulation  necrosis  which  actually  does  occur  in  the  cells  of 
the  decidua  and  in  the  epithelium  of  the  chorionic  villi,  the  ovum 
is  supposed  to  begin  to  act  like  a  foreign  body,  irritating  the  uterine 
nerves,  and  sending  a  reflex  stimulus  to  the  nervous  centres  by 
which  uterine  contractions  are  excited.  This  view  would  explain 
the  causation  of  false  labour  in  cases  of  extra-uterine  pregnancy, 
and  perhaps  also  the  death  of  the  extra-uterine  foetus  at  full  term, 
since  an  analogous  change  may  take  place  in  the  extra-uterine 
placenta.^     If  the  thrombosis  in  the  uterine  veins  of  the  placental 

1  According  to  Leopold,  "  Studien  liber  die  8chleimhaut  des  Uterus,"  Arch.  f. 
Gynak.  XL,  p.  49,  fatty  degeneration  of  the  decidua  before  labour  is  not  a  constant 
occurrence,  but  there  is  always  a  change  in  the  layer  where  separation  is  to  take  place, 
consisting  of  a  thinning  of  the  trabeculse  which  hold  together  the  network  of  spaces 
existing  at  that  level  of  the  decidua. 


Labour.  205 

site,  described  by  some,  is  a  normal  occurrence,  tbis  will  aid  in 
bringing  on  labour,  by  producing  some  obstruction  to  the  blood 
current  through  the  placenta,  and  so  leading  to  increased  venosity 
of  the  foetal  blood  and  a  deficiency  of  oxygen  in  the  utero-placental 
vessels.  It  is  well  known  that  lack  of  aerated  blood,  such  as  occurs 
in  asphyxia,  tends  to  produce  uterine  contraction  and  expulsion  of 
the  foetus. 

Spiegelberg  proposes  the  theory  that  about  full  term  some  change 
takes  place  in  the  nutritive  requirements  of  the  foetus,  so  that  it 
needs  some  substance  not  supplied  through  the  placenta,  and  dies 
if  it  does  not  obtain  it ;  that,  on  the  other  hand,  it  no  longer  requires 
some  substance  hitherto  supplied  to  it,  that  this  substance  accumu- 
lates in  the  maternal  blood,  acts  as  a  chemical  irritant  to  the 
nervous  centres,  and  so  induces  uterine  contractions. 

Schaeffer  ^  propounds  the  theory  that  the  effect  of  the  increasing 
distension  of  the  uterus  in  tending  to  cause  uterine  contractions  is 
inhibited  by  some  body  circulating  in  the  mother's  blood  and  derived 
from  the  cells  of  the  syncytium,  the  so-called  syncytiotoxine,  and 
that  the  action  of  such  a  body  is  evidenced  by  the  changes  occurring 
in  the  maternal  blood  during  pregnancy. 

These  changes  he  describes  as  essentially  a  diminution  in  the 
number  of  the  red  blood  corpuscles,  a  diminution  of  their  resisting 
power  to  the  action  of  the  hemolytic  body,  and  a  diminution  in 
the  amount  of  haemoglobin  they  contain.  In  the  later  months  of 
pregnancy  as  a  result  of  these  changes  the  inhibitory  action  on  the 
nerve  centres  becomes  lessened,  the  distension  of  the  uterus  calls 
forth  more  marked  uterine  contractions,  and  these  in  their  turn, 
pressing  the  lower  pole  of  the  ovum  against  the  tissues  of  the  lower 
uterine  segment,  set  up  the  reflex  contractions  which  eventuate  in 
the  onset  of  true  labour.  The  changes  in  the  blood  described 
probably  do  occur,  but  whether  they  are  due  to  some  body  derived 
from  the  syncytium  is  pure  hypothesis  for  which  there  is  no  certain 
proof.  This  view  offers  some  explanation  of  the  occurrence  other- 
wise difficult  to  explain,  that  even  when  the  foetus  dies  in  the  early 
months  labour  often  does  not  ensue  for  some  time.  This  is 
suj^posed  to  be  due  to  the  fact  that  in  some  of  these  cases  the 
syncytium  continues  to  show  signs  of  growth  after  the  death  of  the 
fcetus,  and  so  continues  to  secrete  the  substance  which  exercises  an 
iuhibitoiy  action  upon  the  uterine  contractions. 

It  appears  prol;able  that  one  of  the  most  important  elements  of 
the  causation  may  be  a  periodicity  inherent,  in  some  inexplicable 
manner,  in  the  nervous  centres  associated  with  some  change  in  the 

1  Schaeffer,  Zentrbl.  f.  Gyiiiik.,  1901,  No.  50,  p.  1375. 


2o6  The  Practice  of   Midwifery. 

maternal  metabolism,  and  no  more  to  be  accounted  for  than  the 
menstrual  periodicity  of  twenty-eight  days,  which  itself  also  appears 
to  have  its  seat  in  the  nervous  centres  and  to  be  associated  with 
certain  changes  in  the  body  metabolism,  as  evidenced  by  the 
occurrence  of  attacks  of  diarrhoea,  migraine,  vertigo,  diminution  in 
the  hfemolytic  resistance  of  the  red  blood  corpuscles,  changes  in  the 
composition  of  the  blood,  and  a  fall  in  the  blood  pressure,  which 
have  been  shown  to  occur  at  these  periods  in  certain  women. 

The  essential  element  in  the  process  by  which  the  foetus  is 
expelled  consists  in  the  contractions  of  the  uterus  ;  the  auxiliary 
force  supplied  by  the  voluntary  muscles  is  only  a  minor  factor. 
This  is  proved  by  the  fact  that,  in  cases  of  paraplegia,  where  the 
abdominal  muscles  are  paralysed,  labour  may  be  completed  in  a 
natural  manner,  while,  on  the  other  hand,  in  uterine  inertia,  where 
the  pains  are  absent,  no  voluntary  effort  can  make  the  labour 
progress. 

Nervous  Mechanism  of  Uterine  Contractions. — The  uterus 
is  quite  independent  of  any  direct  control  of  volition.  Contractions 
may  go  on  rhythmically  when  a  woman  is  perfectl}^  insensible  from 
apoplexy,  from  the  coma  of  puerperal  convulsions,  or  the  narcosis 
of  anaesthetics.  It  is,  however,  much  under  the  indirect  influence 
of  emotions.  The  accoucheur  often  finds  disagreeable  evidence  of 
this  fact  when,  in  the  case  of  a  sensitive  woman,  his  entry  into  the 
room  is  sufficient  to  banish  the  pains,  which  just  before  were 
recurring  regularly.  If  he  takes  his  leave  in  impatience,  the  pains 
are  apt  to  return,  and  the  child  to  be  born  quickly  in  his  absence. 
Again,  it  is  found  greatly  to  conduce  to  the  favourable  progress  of 
labour  to  keep  up  the  woman's  courage  and  hopeful  anticipation  of 
its  conclusion.  The  effect  of  mental  shocks  or  sudden  frights  in 
bringing  on  premature  uterine  contractions  is  well  known.  In 
protracted  labour  also,  the  effect  on  the  woman's  mind  of  prepara- 
tions for  the  application  of  forceps  sometimes  acts  as  such  a  stimulus 
to  the  pains  that  artificial  assistance  becomes  needless.  After 
delivery  not  only  will  suckling  induce  a  sympathetic  contraction  of 
the  uterus,  but  the  maternal  emotions  induced  by  seeing  the  infant 
have  the  same  effect.  In  these  cases  a  stimulus,  or  in  some  cases 
even  an  inhibitory  action,  must  be  transmitted  from  the  brain  to  the 
centres  in  the  spinal  cord. 

The  chief  causes  of  uterine  contraction  are  two :  first,  periodic 
centric  discharge  of  nervous  energy  ;  secondly,  reflex  stimulus. 
The  centric  discharges  of  energy  are  manifested  throughout  preg- 
nancy by  the  periodic  gentle  uterine  contractions,  alternating  with 


Labour.  207 

relaxation.  The  tendency  to  periodic  discharge  is  preserved  during 
labour,  when,  though  receiving  a  more  or  less  constant  afferent 
impulse  from  the  nerves  of  the  uterus  and  vagina,  the  spinal 
centres  send  out  their  stimulus  to  the  uterus  only  at  intervals.  The 
centric  discharge  is  capable  of  being  excited  by  certain  substances 
circulating  in  the  blood,  such  as  ergot  and  other  drugs,  or  an  excess 
of  carbonic  acid.  It  is  probably  also  excited  by  some  morbid 
material  in  the  blood  when  premature  labour  is  brought  on  by  some 
zymotic  disease,  more  especially  small-pox,  or  by  any  very  serious 
illness  of  the  mother. 

Eeflex  stimulus  may  act  upon  the  uterus  in  two  ways,  either  when 
it  is  applied  to  sensitive  cerebro-spinal  nerves,  or  to  sympathetic 
nerves.  As  instances  of  the  first  we  have  the  uterine  contractions 
excited  by  suckling,  or  other  stimulus  applied  to  the  breasts,  or  by 
the  sudden  application  of  cold  to  any  part  of  the  surface  of  the 
body.  In  labour  the  pressure  of  the  head  upon  the  vagina  and 
perineum,  external  pressure  upon  the  perineum,  or  the  introduction 
of  the  hand  into  the  vagina  to  make  an  examination,  have  a  similar 
effect  in  exciting  pains.  Of  reflex  stimulus  excited  by  irritation 
applied  to  sympathetic  nerves,  and  unaccompanied  by  pain,  we  find 
the  chief  instance  in  the  nerves  of  the  uterus  itself.  If  the  ovum 
is  dead  it  acts  like  a  foreign  body,  and  generally  soon  excites  the 
uterus  to  expel  it,  although  in  exceptional  cases  it  may  be  retained 
for  months.  It  acts  in  a  similar  way  as  a  foreign  body  if  the 
membranes  are  separated  from  the  uterine  wall  over  a  considerable 
surface,  or  if  the  liquor  amnii  is  allowed  to  escape  and  let  the 
uterine  wall  come  into  close  contact  with  the  foetus.  Again,  the 
mode  of  inducing  labour  by  passing  up  a  bougie  between  the  mem- 
branes and  the  uterine  wall  and  leaving  it  there  is  an  instance  of 
reflex  stimulus  applied  through  sympathetic  nerves.  Further,  the 
irritation  caused  by  the  dilating  pressure  of  the  bag  of  membranes 
or  the  fcetal  head  upon  the  cervix  and  on  the  ganglion  cervicale  is 
the  chief  element  in  the  mechanism  by  which  labour  goes  on 
automatically  when  once  started. 

Arrangement  of  Nerve  Centres  and  Afferent  Nerves. — 
Experiments  on  animals  appear  to  show  that  two  centres  for  uterine 
contraction  exist  in  the  spinal  cord,  one  in  the  medulla  oblongata 
and  one  in  the  lumbar  portion  of  the  cord,  and  also  that  the 
separated  uterus  has  in  some  degree  a  power  of  rhythmic  action, 
in  virtue  of  the  nerve  centres  contained  in  it.  The  centre  in  the 
medulla  must  be  the  centre  for  reflex  stimuli  transmitted  by  the 
cerebro-spinal  nerves  of  the  upper  part  of  the  body,  and  this  centre 


208 


The   Practice  of   Midwifery. 


appears  to  be  excited  to  action  by  the  presence  of  an  undue  amount 
of  carbonic  acid  in  the  blood.  The  centre  in  the  lumbar  part  of  the 
cord  appears  to  be  that  more  immediately  governing  the  uterus. 
Stimuli  are  transmitted  to  it  through  the  cord  from  the  centre  in 


Fig.  126. — Diagram  of  nerves  of  uterus.  j)hr.,  phrenic  ;  vag.,  vagus  ;  spl., 
splanchnic  ;  hoI.  pl.^  solar  plexus  ;  r.  g.,  renal  ganglion  ;  or.  g.,  ovarian 
ganglion  ;  i.  m.  g.,  inferior  aortic  plexus  ;  liy.  pi.,  hypogastric  plexus  ; 
s.  i.,  sacral  nerves;  s.  sy.  1,  2,  3,  4,  sacral  sympathetic  ganglia;  c.  g., 
cervical  ganglion  ;  ut.,  uterus ;  M.,  bladder  ;  v.,  vagina. 


the  medulla,  and  indirectly,  in  the  case  of  emotions,  from  the  brain. 
The  act  of  parturition  is  partly  automatic  and  partly  reflex,  and 
direct  communication  with  the  brain  is  not  essential  to  co-ordinate 
uterine  action  ;  on  the  other  hand,  direct  communication  between 
the  uterus  and  the  lumbar  enlargement  of  the  cord  through  the 
medium  of   the    sympathetic   chain   between   the  first   and  third 


Labour.  209 

lumbar  ganglia  is  essential  to  regular  contraction  and  retraction  of 
the  uterus.      It  seems  also  probable  that  the  uterus  is  able  auto- 
matically to  expel  its  contents  as  far  as  the  relaxed  portion  of  the 
genital  canal  even  when  deprived  absolutely  of  any  spinal  influence, 
the  spinal  reflexes  being  then  necessarily  absent  (Amand  Eouth^). 
The  nerves  carrying  the  stimulus  to  the   uterus   belong   to   the 
sympathetic  system,  but  these  derive  filaments  from  the  spinal  cord 
through  the  lumbar  and  sacral  nerves  which  join  the  sympathetic 
plexuses.     The  body  of  the  uterus  is  supplied   chiefly   from   the 
inferior  aortic  plexus,  a  central  plexus  lying  upon  the  bifurcation  of 
the  aorta,  which  receives  branches  from  the  lumbar  ganglia  of  the 
sympathetic  as  well  as  from  the  spinal  nerves,  and  is  connected  with 
the  ovarian  (spermatic)  plexus  (Fig.  126) .     Lower  down  the  inferior 
aortic  plexus  divides  into  two  hypogastric  plexuses,  one  at  each 
side,   which   supply   the   rectum   and  the  vagina,  and  also  send 
branches  to  the  lower  part  of  the  body  of  the  uterus  and  the  cervix. 
Branches  from  the  hyj)ogastric  plexus,  together  with  other  branches 
from  the  second,  third,  and  fourth  sacral  nerves,  and  from  the 
lower  lumbar  and  upper  sacral  ganglia  of  the  sympathetic,  unite 
to  form  what  has  been  variously  regarded   as   a  ganglion,  or  a 
plexus  including  many  ganglia,  and  has  been  called  the  ganglion 
cervicale  uteri,  or  the  fundamental  plexus  of  the  uterus  (Pissemski^). 
According  to  Jastreboff,^  there  are  really  two  groups  of  ganglia, 
the  anterior  or  utero-vesical  ganglia,  supplying  not  only  the  cervix, 
but  the  body  of  the  uterus  and  bladder,  and  the  posterior  or  recto- 
vaginal ganglia,   supplying  mainly  the  rectum   and   vagina,    and 
sending  branches  to  the  broad  ligaments.     These  grou^js  of  ganglia 
are  situated  behind  and  at  the  side  of  the  u]3per  part  of  the  vagina. 
Kniipffer  ^  also  describes  two  smaller  ganglia  lying  on  either  side  of 
the  cervix,  the  paracervical  ganglia.     In  pregnancy  these  ganglia 
undergo   marked   hypertrophy,    and    form    a    considerable    mass 
surrounding  the  cervix. 

Mode  in  which  the  Uterus  contracts.  —  The  intermittent 
character  of  the  pains  in  labour  has  an  important  practical  advan- 
tage both  for  the  mother  and  foetus.  The  relaxation  of  the  pressure 
on  the  soft  parts  allows  their  circulation  to  go  on  freely  between 
the  pains,  and  so  diminishes  the  risk  of  damage  to  them  from  pro- 
longed pressure.  The  intervals  of  rest  also  allow  both  the  nervous 
centres  and  the  general  system  of  the  mother  to  recover  energy. 

1  Kouth,  Trans.  Obst.  Soc.  London,  1897,  Vol.  LIX.,  p.  191. 

2  Pissemski,  Monatsschr.  f.  Gcb.  u.  Gyn.,  1903,  Vol.  XVII,,  p.  3. 

"  "  On  the  Ganglion  Cervicale  Uteri."  Trans.  Obst.  Soc.,  London,  1881,  Vol.  XXIII., 
p.  273. 

Kniipffer,  (Jrsache  des  Geburteintrittes.,  Dissert.,  Dorput,  1892. 
M.  14 


2IO  The  Practice  of   Midwifery. 

As  regards  the  foetus,  its  life  would  be  imperilled  by  the  diminution 
of  the  circulation  through  the  uterus  and  placenta  produced  by 
uterine  contraction,  if  the  pains  were  continuous.  Thus,  when  in 
over-protracted  labour  the  uterus  gets  into  a  state  of  continuous 
tetanic  contraction,  the  life  of  the  child  is  generally  lost,  and  the 
exhaustion  of  the  mother  soon  becomes  very  grave. 

The  contraction  of  the  uterus,  like  that  of  other  organs  having 
unstriped  muscular  fibres,  is  not  only  involuntary,  but  peristaltic. 
The  peristaltic  action  is  not,  however,  of  a  very  obvious  kind,  as  is 
j)roved  by  the  very  different  accounts  which  have  been  given  of  it. 
It  has  often  been  said  that  the  contraction  begins  at  the  cervix, 
spreads  thence  to  the  fundus,  and  finally  returns  to  the  cervix 
again.  The  truth  appears  to  be,  that  it  begins  at  the  fundus  and 
spreads  to  the  cervix.  The  pressure  of  the  contracting  wall  on 
the  liquor  amnii  would  naturally  cause  bulging  of  the  bag  of 
membranes  and  apparent  recession  of  the  presenting  part  at  the 
commencement  of  a  pain,  the  membranes    being   unruptured,    a 


I     I     I    I    IT 


•|  I  I  I  I  I  r 


Fig.  127. — Diagram  of  curve  taken  with  the  tocodynamometer  of  pains  of  first 

stage  of  labour.i 

circumstance  which  has  been  given  as  a  reason  for  supposing  that 
contraction  begins  at  the  cervix.  The  time  occuj)ied  by  the  wave 
of  contraction  in  spreading  over  the  uterus  is,  however,  very  small 
as  compared  with  the  whole  duration  of  a  pain,  and  therefore  the 
mechanical  effect  is  that  of  a  continuous  and  not  of  a  peristaltic 
contraction.  In  the  case  of  those  animals  wheie  several  foetuses 
are  contained  in  one  horn  of  the  uterus,  each  fcetus  in  turn  is 
conveyed  to  the  vagina  by  a  true  peristaltic  action,  and  the  direc- 
tion of  the  wave  of  contraction  is  then  from  the  fundus  to  the 
cervix. 

The  uterine  contractions  follow  a  certain  rhythm,  but  this  rhythm 
varies  in  the  course  of  labour.  Each  pain  has  a  period  of  increase, 
a  period  of  greatest  intensity,  and  a  period  of  decline.  Then 
follows  a  period  of  relaxation,  considerably  longer  than  the  whole 
pain  (Fig.  127).  As  labour  advances  and  the  uterine  cavity  becomes 
smaller  by  the  progress  of  the  foetus,  the  uterine  walls  necessarily 
become  thicker.  The  pains  then  become  more  vigorous,  especially 
if  there  is  considerable  resistance,  and  at  the  same  time  the  rhythm 

1  Schatz.  Arch.  f.  Gynak.,  Vol.  III.,  Table  II.,  Curve  II. 


Labour. 


21  I 


is  altered.  The  intervals  become  less  in  proportion,  and  in  each 
pain  the  period  of  greatest  intensity  is  prolonged  while  the  periods 
of  increase  and  decline  become  relatively  less.  If  the  uterine 
muscles  and  nervous  centres  are  well  nourished,  the  intensity  of  the 
pains  is  increased  in  proportion  to  the  resistance  encountered,  so 
long  as  the  woman  does  not 
become  exhausted. 


V 


Retraction  of  the  Uterus. — 

The  progressive  diminution  in 
the  capacity  of  the  uterine  cavity 
which  takes  place  during  the 
second  stage  of  labour,  and  to  a 
very  marked  degree  indeed  after 
the  birth  of  the  child,  is  due  not 
only  to  the  contractions  of  the 
uterine  muscle,  but  also  to  the 
property  it  possesses  of  retrac- 
tion. Each  successive  contrac- 
tion of  the  uterine  musculature 
is  followed  by  some  permanent 
shortening  of  the  individual 
muscle  fibres ;  and  in  this 
manner  their  action,  for  example, 
in  expelling  the  child  is  ren- 
dered continuous  and  lasting. 
As  the  second  stage  progresses 
the  uterine  wall  becomes 
markedly  thicker,  and  this  is 
due  to  the  retraction  of  the 
muscle,  which  leads  to  a  re- 
arrangement of  the  fibres  so 
that  they  become  placed  to  a 
greater     degree    side     by    side, 

and  at  the  same  time  become  shorter  and  thicker,  and  so  cause  a 
considerable  degree  of  compression  of  the  arteries  and  veins  which 
lie  between  them  (Fig.  128).  The  power  of  retraction  which  the  uterus 
exhibits  in  common  with  other  hollow  viscera,  such  as  the  bladder, 
is  of  the  greatest  importance  therefore  in  maintaining  the  progress 
made  by  each  successive  contraction  in  the  expulsion  of  the  foetus, 
in  the  separation  of  the  placenta,  and,  most  important  of  all,  in  pre- 
Yeni'mg ])OHtj)art'uiiL  haemorrhage  by  the  compression  and  obliteration 
of  the  vessels  in  the  uterine  wall  which  it  brings  about.     In  cases 

14—2 


Fig.  128. — Diagram  showing  sliorten- 
ing  and  thickening  of  uterine  muscle 
fibres,  and  obliteration  of  lumen 
of  arteries  and  veins,  e.g.,  the  result 
of  retraction.  On  left,  non-con- 
tracted muscle  fibres  of  pregnant 
uterus  ;  on  right,  same  area  repre- 
sented contracted  and  retracted. 


212  The   Practice  of   Midwifery. 

of  obstructed  labour  in  which  retraction  occurs  to  an  excessive 
degree  the  Une  of  demarcation  between  the  contracted  and  retracted 
upper  uterine  segment  and  the  distended  lower  uterine  segment  is 
shown  by  the  marked  formation  of  the  so-called  retraction  ring,  a 
sign  clinically  of  the  utmost  importance. 

Polarity  of  the  Uterus. — The  circular  muscular  fibres  of  the 
cervix  do  not  contract  in  conjunction  with  the  rest  of  the  muscular 
wall ;  but,  on  the  contrary,  there  is  a  nervous  correlation  between 
them  of  such  a  kind  that,  with  contraction  of  the  body  of  the  uterus, 
and  especially  with  regular,  rhythmical,  intermittent,  expulsive 
contractions,  such  as  occur  in  labour,  there  is  associated  a  physio- 
logical yielding  of  the  sphincter  muscles  of  the  cervix,  including 
both  internal  and  external  os.  Conversely,  when  the  body  of  the 
uterus  is  inactive,  the  circular  fibres  of  the  cervix  are  generally  in 
action,  and  mechanical  dilatation  of  the  cervix  tends  to  excite  con- 
traction in  the  body  of  the  uterus.  These  facts  were  made  the 
basis  of  rather  a  fanciful  description  by  Reil,^  who  held  that  in  the 
uterus  contraction  and  expansion  are  forces  naturally  in  equipoise, 
but  capable  of  polar  divergence.  His  view  was,  that  in  the  unim- 
pregnated  uterus  there  is  no  divergence  of  the  forces,  contraction 
predominating  ;  that  in  pregnancy  expansion  retreats  to  one  pole, 
the  fundus,  and  contraction  to  the  other  pole,  the  cervix  ;  but  that, 
on  the  onset  of  labour,  contraction  leaps  over,  as  in  an  overcharged 
jar,  from  the  cervix  to  the  fundus,  and  expansion  retreats  to  the 
cervix  ;  while,  after  delivery,  the  forces  again  come  into  equipoise, 
with  a  preponderance  of  contraction. 

The  term  "polarity  of  the  uterus"  is  a  convenient  one,  as  a 
concise  expression  of  the  facts,  but,  in  reality,  the  explanation  of 
the  phenomena  seems  to  be  a  simple  one,  and  to  show  no  real 
analogy  to  electric  polarity.  The  nervous  correlation  by  which 
the  action  of  the  detrusor  muscle  is  associated  with  physiological 
yielding,  not  merely  passive  stretching,  of  the  sphincter  muscle 
which  retains  the  contents  of  the  cavity  is  shared  by  the  uterus 
with  other  hollow  viscera,  such  as  the  rectum  and  bladder,  and  in 
all  cases  the  arrangement  subserves  the  same  obvious  purpose.  In 
the  case  of  the  uterus  the  physiological  yielding  and  relaxation  in 
labour  appear  to  affect  not  only  the  cervix,  but  the  muscular  wall 
of  the  vagina.  In  all  the  cases  spasm  of  the  sphincter  is  apt  to  be 
associated  with  inactivity  of  the  expulsive  muscle.  In  the  uterus, 
however,  there  seems  to  be  a  further  nervous  correlation.     In  order 

1  See  Eeil,  Archiv.  f .  Physiologie,  1807,  VII.,  p.  415;  and  Charapneys'  "Notes  on 
Uterine  Polarity,"  Obstet.  Journ.,  1880,  VII. 


Labour.  213 

to  make  labour  go  on  automatically  when  once  started,  it  is  arranged 
that  the  stretching  of  the  cervix  by  the  bag  of  membranes  or  the 
foetus  should  cause  by  reflex  action  expulsive  contraction  of  the 
body.  The  same  tendency  is  shown  by  the  uterus,  to  some  extent, 
at  other  times,  even  when  unimpregnated.  Thus  in  cases  of 
haemorrhage,  with  laxity  of  the  fundus  and  a  narrow  cervix, 
mechanical  dilatation  of  the  cervix  will  sometimes  arrest  the 
hseraorrhage  by  stimulating  the  body  of  the  uterus  to  contract  and 
close  the  vessels.  Similarly  at  any  stage  of  pregnancy  mechanical 
dilatation  of  the  cervix  will  generally  set  up  expulsive  i^ains. 
Whether  or  not  it  be  called  polarity,  this  relation  between  the  body 
and  the  cervix  is  frequently  exemplified  ;  and  when  from  any 
nervous  aberration,  whether  of  local  or  general  origin,  there  is  an 
abnormal  condition  of  the  one,  the  condition  of  the  other  is  usually 
modified  in  the  converse  direction.  Thus,  when  there  is  a  spasmodic 
contraction  or  "trismus"  of  the  os  or  cervix  uteri,  there  is  almost 
always  a  deficiency  in  rhythmical  and  regular  expulsive  pains.  If 
the  OS  can  be  dilated,  the  pains  will  generally  come  on  regularly, 
and  conversely,  if  rhythmical  pains  can  be  excited,  physiological 
yielding  of  the  os  and  cervix  will  generally  take  place.  It  is  pro- 
bable that  in  the  gentle  uterine  contractions,  which  take  place 
apart  from  labour,  and  are  not  expulsive  in  their  functions,  the 
strong  sphincter  fibres  which  surround  the  internal  os  contract 
with  the  rest  of  the  body  of  the  uterus,  and  prevent  any  tendency 
to  dilatation.  Sometimes  this  may  be  observed  to  take  place  even 
in  labour,  when  there  is  a  tendency  to  spasm  of  the  cervix,  associ- 
ated with  deficiency  of  expulsive  j^ains,  especially  when  the  liquor 
amnii  has  escaped  prematurely.  The  effect  of  a  pain  may  then  be 
actually  somewhat  to  close  up  the  internal  or  external  os,  instead 
of  to  dilate  it  further. 

Cause  of  the  Pain  in  Labour. — The  severe  pain  which  almost 
invariably  accompanies  labour  is  chiefly  twofold  in  its  origin. 
First,  there  is  the  pain  produced  in  the  uterine  muscle  itself  during 
its  contraction.  This  is  analogous  to  the  pain  of  colic,  and  is 
probably  due  to  the  compression  of  the  nerve  filaments.  This 
kind  of  pain  is  felt  mainly  in  the  abdomen,  over  the  surface  of  the 
uterus.  Secondly,  there  is  the  pain  produced  by  the  stretching  of 
the  soft  parts,  the  pressure  upon  them,  and  also  by  the  strain  upon 
the  uterine  ligaments  and  attachments,  when  the  uterine  contrac- 
tion meets  with  much  resistance.  In  the  early  stage  of  labour  this 
kind  of  pain  is  due  to  the  stretching  of  the  cervix,  and  especially  of 
the  margin  of  the  external  os.      The  pain  so  produced  is  generally 


214  The   Practice  of   Midwifery. 

a  dull,  aching  pain,  and  is  felt  chiefly  over  the  upper  part  of  the 
sacrum.  As  the  foetus  advances,  pain  is  produced  by  stretching  of 
the  vagina,  and  especially  of  the  perineum  and  vaginal  outlet. 
This  is  often  of  a  violent  tearing  character,  and  very  intense, 
especially  in  primiparae,  since  the  genital  passage  becomes  more 
and  more  sensitive  towards  its  outlet,  and  in  primiparae  stretching 
never  suffices,  and  some  laceration  of  the  vaginal  outlet,  at  the  site 
of  the  hymen,  is  inevitable.  In  the  later  stage  of  labour  there  is 
often  also  pain  running  down  the  thighs,  and  violent  cramps  in  the 
thighs  and  legs,  due  to  pressure  upon  the  sacral  plexus.  The  inten- 
sity of  the  pain  in  labour  varies  very  greatly  in  different  persons,  in 
some  degree  of  accordance  with  the  amount  of  resistance  experienced, 
but  more  especially  in  proportion  to  the  nervous  susceptibility  of 
the  patient.  This  applies  especially  to  the  pain  produced  by  the 
contraction  of  the  uterine  muscle  itself.  This  in  some  cases  is 
agonising,  while  in  others  it  is  very  easily  endurable.  In  very 
exceptional  cases  labour  is  gone  through  without  any  sensation 
which  could  be  considered  as  amounting  to  pain,  and  labour  has 
even  commenced  during  sleep  and  been  completed  without  the 
mother  being  awakened.  In  such  cases  there  must  have  been 
gradual  and  easy  dilatation,  and  so  little  resistance,  that  a  very 
slight  force,  perhaps  one  not  much  exceeding  the  weight  of  the 
child,  has  been  sufficient  to  effect  delivery. 

Effect  of  the  Pains  on  the  General  System. — During  a 
pain  the  pulse  becomes  gradually  accelerated  till  the  pain  reaches 
its  height ;  as  the  pain  subsides  the  pulse  falls  again,  and  in  the 
interval  of  rest  returns  to  its  former  rate.  The  acceleration 
at  each  pain  may  be  as  much  as  from  20  to  24  beats  per  minute. 
If  labour  is  prolonged,  there  is  also  progressive  acceleration  of  the 
minimum  pulse-rate.  The  converse  effect  on  the  fcBtus  of  diminu- 
tion of  the  heart-rate,  both  during  a  pain,  and  progressively  in 
prolonged  labour,  has  been  already  described  (see  p.  186). 

A  rise  in  the  maternal  blood  pressure  occurs  during  the  first 
stage  of  labour,  becomes  more  marked  with  the  increase  in  the 
intensity  of  the  pains  during  the  second  stage,  and  reaches  its 
highest  point  at  the  moment  of  the  birth  of  the  child.  Immediately 
after  this  the  blood  pressure  sinks  to  a  marked  degree,  and  reaches 
its  minimum  with  the  expulsion  of  the  placenta.  On  the  comple- 
tion of  delivery  it  gradually  rises,  but  it  does  not  as  a  rule  reach  the 
normal  level  until  about  the  fifth  day  of  the  puerperium. 

There  is  some  elevation  of  temperature  also  in  labour.  Normally 
it  is  but  slight,  but,  in  protracted  labour,  it  may  amount  to  as  much 


Labour.  215 

as  two  or  three  degrees  Fahrenheit.     The  respiratory  rate  is  also 
somewhat  quickened. 

In  sensitive  women  who  feel  the  labour  pains  very  acutely,  labour 
may  give  rise  to  extreme  nervous  disturbance.  Vomiting  is 
frequent,  hysterical  manifestations  are  not  uncommon,  and  some- 
times at  the  stage  of  most  acute  pain,  when  the  head  is  passing  the 
vulva,  the  woman  loses  all  control  over  herself,  and  becomes 
scarcely  responsible  for  her  actions.  Rigors  sometimes  occur, 
without  any  notable  elevation  of  temperature,  especially  about  the 
time  of  full  dilatation  of  the  os,  and  the  body  is  not  infrequently 
bathed  in  jperspiration. 

The  Course  of  Parturition. 

Premonitory  Symptoms.— For  a  week  or  two  before  delivery, 
the  uterus  generally  sinks  deeper  into  the  pelvis,  while  the  fundus, 
in  the  upright  position  of  the  woman,  falls  more  forward,  and  thus 
becomes  lower.  Symptoms  of  pressure  on  the  chest  and  epigastric 
region  are  thereby  generally  relieved.  From  the  increased  pelvic 
pressure,  there  is  often  frequent  micturition,  some  increase  of 
difficulty  in  walking,  and  the  vaginal  secretion  becomes  more 
abundant.  There  is  often  also  irritability  of  the  rectum  at  this 
time ;  and  this,  when  it  occurs,  has  the  advantage  of  freeing  the 
pelvis  from  any  collection  of  faeces.  Exceptionally  in  primiparae, 
as  already  described  (see  p.  155),  the  internal  os  becomes  expanded 
by  painless  contractions,  so  that  the  bag  of  membranes  rests  upon 
the  external  os,  but  in  the  great  majority  of  cases  the  cavity  of  the 
cervix  remains  distinct  from  that  of  the  uterus  until  the  definite 
commencement  of  labour.  In  some  cases,  especially  in  pluriparae, 
no  premonitory  signs  at  all  are  noticed,  and  labour  begins  quite 
suddenly.  In  others,  besides  the  symptoms  already  mentioned,  the 
uterine  contractions  which  occur  throughout  pregnancy  increase  in 
degree,  and  eventually  become  manifest  to  the  woman  herself, 
although  they  are  manifest  earlier  on  examination  by  another 
person.  Such  slight  pains  may  recur  for  a  few  hours  every 
evening  for  several  successive  days,  and  occasionally  may  pass  off 
altogether  for  some  time  before  merging  into  actual  labour. 

Spurious  Pains. — The  name  of  spurious  or  false  labour  pains 
is  given  to  pains  which  often  occur  during  the  stage  preliminary  to 
labour,  and  which  are  distressing  to  the  woman,  and  sometimes 
lead  her  to  send  for  her  medical  attendant,  in  the  belief  that  labour 
is  actually  in  progress.  They  consist  of  painful  uterine  contrac- 
tions which  are  generally  partial  and  irregular,  and  are,  at  any 


2i6  The   Practice  of   Midwifery. 

rate,  unaccompanied  by  any  physiological  yielding  of  the  cervix. 
They  are  distinguished  by  the  fact  that  they  produce  no  dilatation 
of  the  OS,  and  are  not  accompanied  by  the  copious  lubricating 
secretion  from  the  cervix,  which  is  poured  out  in  actual  labour, 
and  by  the  absence  of  any  show,  or  blood  in  the  vaginal  discharge, 
such  as  occurs  when  labour  has  really  commenced,  and  is  produced 
by  the  sej)aration  of  the  membranes  from  the  lower  uterine 
segment.  Such  spurious  pains  are  often  set  up  by  some  local 
irritation,  such  as  digestive  disturbance,  or  accumulation  of  faeces, 
and  are  then  relieved  by  an  aperient  or  enema. 

The  Three  Stages  of  Labour, — It  is  usual  to  divide  labour  into 
three  stages.  The  first  stage  is  that  of  the  dilatation  of  the  cervical 
canal  and  external  os ;  the  second  or  expulsive  stage  comprises  the 
period  from  the  full  dilatation  of  the  cervix  up  to  the  complete 
expulsion  of  the  foetus ;  the  third  stage  is  that  of  the  delivery  of 
the  placenta. 

The  First  Stage. — There  are  three  elements  in  the  mechanism  of 
dilatation  of  the  cervix  and  external  os  :  first,  the  mechanical 
stretching  by  the  bag  of  membranes,  or  part  of  the  fcetus  projecting 
into  the  cervix ;  secondly,  the  contraction  of  the  longitudinal  fibres 
of  the  uterus,  which  draw  the  cervix  open;  and  thirdly,  the 
physiological  relaxation  of  the  circular  fibres,  which  has  already 
been  described  (see  p.  212)  as  taking  place  in  conjunction  with  the 
contraction  of  the  body  of  the  uterus.  It  follows  from  the  principles 
of  mechanics  that  the  effect  of  any  given  pressure  within  the  bag 
of  membranes  in  producing  a  tension  of  the  edge,  either  of  the 
internal  or  external  os,  is  directly  proportional  to  the  diameter  of 
the  OS,  and  therefore  vanishes  when  the  os  is  very  small.  Hence, 
if  the  OS  is  closed  to  begin  with,  some  dilatation  by  the  stretching 
influence  of  the  longitudinal  fibres  must  take  place  before  the 
mechanism  of  dilatation  by  the  bag  of  membranes,  or  parts  of  the 
foetus,  can  come  into  play. 

This  is  what  actually  does  occur :  the  contraction  of  the  longi- 
tudinal fibres  of  the  uterine  wall  draws  open  the  internal  os,  causes 
a  slight  degree  of  separation  of  the  membranes  in  its  immediate 
neighbourhood,  and  so  enables  this  portion  of  the  membranes  to 
bulge  into  the  dilated  upper  extremity  of  the  cervical  canal.  The 
mechanical  action  of  the  dilating  part,  as  it  is  pressed  into  the 
cervix,  is  that  of  a  wedge  :  a  fluid  and  uniform  wedge  in  the  case 
of  the  bag  of  membranes ;  a  solid  and  irregular  wedge  in  the  case 
of  the  head  or  other  part  of  the  fcetus.  It  follows  that  the  effect 
produced  by  the  wedge  varies  according  to  the  acuteness  of  its 


Labour. 


217 


angle  at  the  points  where  it  is  in  contact  with  the  edge  of  the  os.^ 
It  will  hence  be  readily  understood  why  it  is  that,  when  the 
membranes  are  ruptured,  either  naturally  or  artificially,  before  the 
OS  is  large  enough  to  allow  the  head  to  project  much  through  it, 
the  head  forms  an  extremely  bad  dilator  as  compared  with  the  bag 
of  membranes.  For  it  either  cannot  project  into  the  os  at  all,  or 
projects  so  little  as  to  form  an  extremely  blunt  wedge  instead  of  an 
acute  one. 

The  commencement  of  actual  labour  is  often  very  indefinite. 
The  preliminary  pains,  which  have  been  already  mentioned, 
become  more  marked,  though  still  at  first  slight  and  at  long 
intervals.  Generally  there  takes  place  also  a  discharge  of  mucus, 
tinged  with  blood.  This  depends  upon  separation  of  the  membranes 
from  the  uterus  near  the  internal  os,  or  upon  rupture  of  small 


Fig.  129. — Diagram  of  dilatation  of  cervical  canal  in  a  primipara.  The 
internal  os  dilates  first,  and  the  external  os  remains  almost  closed  until 
the  whole  canal  has  become  obliterated. 

vessels  at  the  edge  of  the  os,  and  it  therefore  indicates  that  the 
pains  are  beginning  to  be  effective  in  producing  dilatation.  It  is 
well  known  to  nurses  under  the  name  of  the  "  show,"  as  a  sign  that 
labour  is  really  commencing.  It  does  not,  however,  invariably  take 
place. 

The  internal  os  is  the  first  to  yield  to  the  effect  of  the  pains,  and 
the  cervix  becomes  expanded  so  as  to  form  one  cavity  with  the 
body,  and  allow  the  bag  of  membranes  with  the  presenting  part  to 
rest  upon  the  external  os,  before  the  external  os  itself  undergoes  any 
notable  dilatation  (Fig.  129).  This  implies  that  a  sufficient  portion  of 
the  bag  of  membranes  must  have  been  detached  from  the  lower 


'  In  mathematical  language,  the  tension  produced  on  the  edge  of  the  os  by  any- 
given  pressure  within  the  membranes  is  directly  proportional,  not  only  to  the  diameter 
of  the  OS,  but  to  the  sine  of  the  angle  which  the  tangent  to  the  projecting  bag  of  mem- 
branes (or  to  the  head  when  tliat  is  acting  as  dilator),  at  the  point  where  it  touches 
the  edge  of  the  os,  makes  with  the  plane  of  the  os.  It  follows  that  the  dilating  force 
vanishes  when  there  is  no  projection,  and  becomes  greater  the  more  complete  is  the 
projection.  It  follows,  also,  that  it  becomes  progi'cssively  more  and  more  effective  in 
proportion  to  the  degree  of  dilatation  which  has  already  been  produced. 


2l8 


The  Practice  of   Midwifery. 


part  of  the  body  of  the  uterus  to  allow  the  bag  to  project  into  the 
cervix,  and  eventually  through  the  external  os.  The  pressure  of 
this  detached  portion  of  the  ovum,  acting  as  a  solid  body,  serves  as 
a  constant  stimulus  to  the  uterus  to  further  contraction,  and 
generally  thus  ensures  the  speedy  expulsion  of  the  fcetus,  although 
in  some  exceptional  cases,  as  already  mentioned  (see  p.  155),  this 
state  of  things  continues  for  some  days,  or  even  weeks,  before  active 
labour.  To  this  constant  stimulus  to  further  contraction  is  added 
the  intermittent  stimulus  of  pressure  on  the  cervical  ganglia  and 
nerves  produced  by  the  pains  themselves.  This  stage  will  generally 
have  been  reached  before  the  medical  attendant  is  summoned.  If 
an  examination  be  then  made  during  a  pain,  before  the  os  is  much 
dilated,  the  edge  of  the  os  will  be  felt,  especially  in  primiparpe,  as  a 
thin,    tense,    almost    membranous   ring,  with   the   tense   bag   of 


Fig.  130. — Diagram  of  dilatation  of  the  cervical  canal  in  a  multiparje.  The 
dilatation  of  the  internal  os  is  accompanied  by  a  dilatation  of  the 
cervical  canal  as  a  whole. 

membranes  projecting  more  or  less  into  it,  so  that  it  is  difficult  to 
feel  the  presenting  part  until  the  pain  has  passed  off.  After  a  time, 
as  the  OS  begins  gradually  to  yield  to  successive  pains,  its  edge 
becomes  softer,  thicker,  and  more  tumid,  and  this  change  is  a  sign 
that  dilatation  will  thenceforth  proceed  more  rapidly.  In  parous 
women  the  edge  of  the  os  is  often  found  soft  and  thick  when  first 
examined. 

The  relaxation  of  the  circular  fibres  and  the  occurrence  of  the 
marked  softening  of  the  cervix  which  is  so  characteristic  of  preg- 
nancy renders  the  dilatation  a  permanent  one  until  the  contents  of 
the  uterus  have  been  expelled.  In  primiparge  the  dilatation  of  the 
external  os  definitely  follows  that  of  the  cervical  canal ;  in  multipara 
the  two  processes  often  go  on  to  a  certain  extent  2^ari  passu,  the 
external  os  dilating  before  the  canal  has  been  entirely  obliterated 
(Figs.  129,  and  130). 

The  amount  of  suffering  experienced  during  the  first  stage  of 
labour  varies  very  much  in  different  persons.     As  a  rule  the  woman 


Labour.  219 

is  able  to  be  up  and  about.  As  the  dilatation  advances  the  pains 
recur  at  progressively  shorter  intervals,  but  each  pain  is  short 
compared  with  the  pains  of  the  expulsive  stage,  not  usually  exceed- 
ing a  minute  in  length.  As  a  general  rule  the  pain  consists  of 
uterine  contraction  only,  and  the  muscles  of  expiration  are  not 
called  into  play  as  auxiliaries.  The  woman  may  cry  out  freely  from 
the  severity  of  the  pain,  and  there  is  no  involuntary  holding  of  the 
breath  for  expulsive  effort.  Towards  the  end  of  the  first  stage  the 
pains  often  recur  more  frequently  than  the  more  prolonged  and 
vigorous  pains  of  the  expulsive  stage,  and  to  women  of  a  susceptible 
nervous  temperament  they  may  be  more  distressing,  partly  because 
the  woman  does  not  feel  that  progress  is  being  made.  When  the 
pains  are  frequent  the  pulse  may  become  more  rapid,  sometimes 
reaching  100,  but  falls  again  after  the  membranes  are  ruptured, 
and  there  are  longer  intermissions  between  the  pains.  Unless  the 
first  stage  has  been  very  long  protracted,  and  provided  that  the 
membranes  are  not  ruptured,  this  increase  of  rapidity  in  the  pulse 
is  not  of  much  moment,  and  has  not  the  same  significance  as  a 
rapid  pulse  in  the  expulsive  stage.  As  the  os  is  dilating,  a  copious 
lubricating  secretion  is  poured  out  by  the  mucous  glands  of  the 
cervix,  and  the  vaginal  walls  become  relaxed  and  dilatable.  The 
presence  of  this  secretion  in  abundance  is  a  very  important  practical 
sign  to  the  accoucheur  that  the  labour  is  likely  to  be  completed 
rapidly.  It  is  of  value  not  only  from  its  own  mechanical  effect,  but 
as  an  indication  that  the  vagina  as  well  as  the  cervix  is  passing  into 
a  suitable  condition  of  preparedness.  Like  the  lubricating  secretion 
poured  out  in  coitus,  it  is  greatly  under  the  influence  of  the  nervous 
system.  It  is  liable  to  be  deficient  when  there  is  a  tendency  to 
spasm  of  the  cervix,  or  a  deficiency  of  rhythmical  pains,  also  when 
there  is  any  source  of  irritation  either  from  any  abnormal  condition 
of  the  genital  passages,  or  from  unduly  frequent  examination  at  an 
early  stage  of  labour.  It  is  also  more  lik&ly  to  be  deficient  if  labour 
is  premature,  especially  if  induced  artificially. 

The  bag  of  membranes,  which  at  first  bulges  at  the  external  os 
only  in  the  form  of  a  watch-glass  (Fig.  196,  p.  296),  protrudes  more 
and  more  as  the  first  stage  advances,  and  eventually  may  form  a 
sausage-shaped  swelling  in  the  vagina  (see  Fig.  131,  p.  220),  and 
even  protrude  externally  at  the  vulva.  When  the  mechanism  of 
nature  is  carried  out  to  the  greatest  perfection,  the  membranes  have 
just  such  a  strength  that,  when  the  os  is  fully  dilated  to  the  width 
of  the  expanded  vagina,  and  not  till  then,  the  pressure  of  the  liquor 
amnii  is  raised  by  the  increasing  pains  up  to  a  point  sufficient  to 
rupture  them.      The  rupture  generally  takes  place  at  the  bulging 


220 


The   Practice  of   Midwifery. 


part ;  the  liquor  amnii  in  front  of  the  head  then  flows  away,  and  a 
portion  also  of  the  rest.  The  head,  however,  being  pressed  down 
into  the  cervix,  fills  it  up  like  a  ball  valve  and  retains  a  certain 
part  of  the  liquor  amnii.      A  portion  of  this  is  retained  until  after 


Fig.  131. — From  a  frozen  section  of  a  patient  who  died  in  labour,  the  head 
having  entered  the  pelvic  cavity,  but  the  membranes  being  yet  unrup- 
tured. L,  liver  ;  S,  stomach  ;  Pa,  pancreas  ;  D,  duodenum  ;  «,  aorta  ; 
PI,  placenta  ;  oi,  os  internum  (.')  or  retraction  ring  {!)  ;  Bl,  bladder  ; 
oe,  OS  externum  ;  «,  urethra  ;  M,  bag  of  membranes  ;  i2,  rectum.  (After 
C.  Braune.) 

the  birth  of  the  foetus,  but  generally  a  little  flows  away  at  the  com- 
mencement of  each  successive  pain,  the  uterine  pressure  beginning 
to  affect  the  liquor  amnii  before  it  has  pressed  the  head  into  firm 
contact  with  the  whole  border  of  the  os  uteri,  or  of  that  part  of  the 
genital  canal  which  it  is  entering.  Thus  the  longer  labour  is  pro- 
tracted the  more  closely  does  the  uterine  wall  come  into  contact 


Labour. 


221 


with  the  foetus.  If  any  other  part  of  the  foetus  than  the  head  or 
breech  presents,  almost  the  whole  of  the  liquor  amnii  flows  away 
immediately.  The  same  result  happens,  if  from  contraction  of  the 
pelvis  the  head  is  arrested  above  the  brim  and  so  prevented  from 
descending  into  and  filling  up  the  os. 


Fig.  132. — From  the  same  section  as  Fig.  131,  the  foetus  being  removed. 
PI,  placenta  ;  ot,  cavity  of  uterus  ;  oi,  os  internum  (.')  or  retraction 
ring  (?)  ;  C,  cavity  of  cervix,  the  ridge  indicated  at  C  is  considered  by 
many  authorities  to  be  the  internal  os  ;  oe,  os  externum  ;  V,  vagina. 
Note  position  of  bladder  and  of  the  peritoneum. 

The  termination  of  the  first  stage  must  be  defined  as  being 
marked,  not  by  the  rupture  of  the  membranes,  but  by  the  complete 
dilatation  of  the  os,  or  at  any  rate  by  its  dilatation  to  such  a  point 
that  it  offers  no  obstacle  to  the  advance  of  the  presenting  part. 
"When  the  rupture  of  the  membranes,  either  by  nature  or  by  art, 
just  coincides  with  such  dilatation,  it  marks  the  transition  from 
the  first  to  the  second  stage.      The  cervix  uteri  is  then  converted 


222 


The  Practice  of   Midwifery. 


into  a  continuous  tube  with  the  vagina  (see  Fig.  132,  p.  221),  the 
vaginal  portion  of  the  cervix  merely  remaining  as  a  flaccid  border 
resting  flat  against  the  dilated  vagina  (oe,  Fig.  132). 

More  frequently  there  is  no  very  well-defined  boundary  between 
the  first  and  second  stages.  The  membranes  give  way,  or  are 
ruptured  artificially,  before  dilatation  of  the  os  is  quite  complete. 
The  pains  then  acquire  the  character  of  those  of  the  second  stage, 
and  the  head  begins  to  advance,  while  there  is  still  a  rim  of  the 

cervix  overlapping  the  greater 
diameter  of  the  head,  and 
forming  a  part  of  the  obstacle 
to  its  progress.  The  effect 
often  is  that  this  rim  of  the 
cervix  is  carried  down,  to  some 
extent,  with  the  head  towards 
the  vaginal  outlet.  If  the 
membranes  rupture  still  earlier, 
before  much  dilatation  of  the 
OS  has  been  eflected,  the  first 
stage  is  liable  to  be  much  pro- 
tracted, and  the  child's  life 
runs  a  greater  risk.  This 
occurs  more  frequently  in 
primiparae,  in  whom  the  os 
presents  a  greater  resistance 
to  dilatation.  So  long  as  the 
membranes  are  intact,  and 
there  is  sufficient  liquor  amnii 
present,  the  head  is  not  pressed 
down  at  all  into  the  os  before 
its  full  dilatation,  but,  on  the 
contrary,  recedes  during  a  pain. 
The  child  being  thus  only  subjected  to  the  equable  pressure  of  the 
liquor  amnii  on  all  sides,  its  circulation  is  not  likely  to  be  seriously 
interfered  with. 

When  the  membranes  are  unusually  tough  and  are  not  ruptured 
artificially,  the  bag  of  membranes  may  be  expelled  quite  outside  the 
vulva,  and  even  the  head  may  pass  through  the  vulva  within  the 
unruptured  membranes.  The  membranes  then  generally  rupture 
about  the  situation  of  the  neck,  after  the  birth  of  the  head.  The 
child  is  popularly  said  to  be  born  with  a  caul,  and  to  the  so-called 
caul  peculiarly  lucky  properties  have  been  superstitiously  attributed. 
When  the  bag  of  membranes  is  thus  carried  down  in  front  of  the 


Fig.  133.  —  Diagram  showing  how  the 
amnion  is  partly  separated  from  the 
placenta  when  it  presents  unruptured 
in  the  vagina  or  at  the  vulva. 
Amnion  =  inner  dotted  line. 


Labour.  223 

head,  the  amnion  is  usually  torn  away  from  the  placenta.  In  most 
cases  the  amnion  alone  forms  the  caul,  the  chorion  having  ruptured 
at  the  usual  place,  and  remaining  attached  to  the  placenta,  but  some- 
times the  caul  is  formed  of  both  membranes  (Fig.  133).  Still  more 
rarely  the  whole  ovum  may  be  expelled  entire,  and  the  child  will 
then  be  suffocated  if  the  membranes  are  not  ruptured  artificially. 
The  uterus  acts  at  a  great  disadvantage  in  propelling  the  fa3tus 
while  the  membranes  are  entire,  not  only  because  the  body  to  pass 
through  the  passages  is  larger,  but  because  it  does  not  itself  gain 
strength  through  the  diminution  of  its  cavity,  and  consequent 
thickening  of  its  walls,  on  the  escape  of  the  liquor  amnii.  Such 
an  event,  therefore,  is  only  likely  to  happen  when  the  child  is 
small  relatively  to  the  pelvis,  and  the  quantity  of  liquor  amnii 
also  comparatively  small.  Occasionally  a  certain  amount  of  water 
escapes  early  in  labour,  and  a  bag  of  membranes  is  nevertheless 
afterwards  found  presenting.  This  generally  depends  on  the 
membranes  having  been  ruptured  not  at  the  os,  but  higher  up 
within  the  uterus,  so  that  after  the  escape  of  a  portion  of  the  liquor 
amnii,  the  opening  is  more  or  less  closed  by  the  pressure  of  the 
presenting  part.  More  rarely  there  is  fluid  between  the  chorion 
and  amnion,  and  two  bags  of  membranes  may  then  be  ruptured  in 
succession.  Occasionally  also  fluid  is  said  to  be  secreted  between 
the  chorion  and  the  uterine  wall,  probably  in  some  remnant  of  the 
decidual  cavity,  and  to  be  expelled  with  the  early  pains. 

Mode  in  ivhich  the  cervix  and  vagina  expand. — The  soft  parts 
which  close  the  pelvic  cavity  below  and  form  the  pelvic  floor,  as 
seen  in  antero-posterior  section,  may  be  regarded  as  made  up  of 
two  triangles,  the  anterior  and  posterior  pelvic  triangles.^  The 
apex  of  the  anterior  triangle  is  at  the  cervix  uteri,  its  base  at  the 
pubes.  The  apex  of  the  posterior  triangle  is  at  the  edge  of  the 
perineum,  its  base  is  formed  by  the  lower  part  of  the  sacrum  and 
the  coccyx.  The  two  triangles  are  separated  by  the  vagina,  which 
forms  a  transverse  slit,  the  weakest  part  of  the  pelvic  floor,  and 
allows  one  triangle  to  slide  upon  the  other  to  some  extent  (see 
Fig.  134,  p.  224).  Of  the  two  the  anterior  triangle  is  the  most 
movable,  since  its  base  only  is  fixed,  and  its  apex  moves  up  and 
down  with  the  cervix  uteri.  The  lower  side  of  the  posterior 
triangle  has  its  mobility  limited  by  its  close  connection  with  the 
lower  end  of  the  rectum,  which  is  held  in  place  by  strong  muscles, 
the  levator  ani  and  others. 

The  mode  in  which  the  vagina  expands  in  labour  is  shown  by 
Braune's  frozen  sections  (Figs.  131, 132,  pp.  220,  221).    The  anterior 

1  See  Hart,  ALlas  of  Female  Pelvic  Anatomy,  pp.  57 — 67. 


224 


The  Practice  of   Midwifery. 


pelvic  triangle  is  drawn  upwards,  while  the  posterior  pelvic  triangle 
is  pushed  downward  by  the  advancing  head.  The  two  triangles 
thus  open  to  let  the  foetus  pass  like  double  swing  doors,  which 
swing  open  in  opposite  directions,  and  thus  convert  the  vagina 
into  a  wide  canal. 

The  tension  produced  by  the  contraction  of  the  longitudinal 
fibres  of  the  uterus  necessarily  exercises  an  upward  traction  upon 
the  cervix  to  which  they  are  attached.     The  anterior  pelvic  triangle 


Fig.  134. — Vertical  section  of  pelvis  in  the  virgin.  1,  body  of  uterus  ;  2,  its 
cavity  ;  3,  the  vaginal  portion  ;  4,  canal  of  cervix  ;  5,  lower  lip  of  os  ex- 
ternum, forming  apex  of  anterior  triangle  ;  6,  vagina  ;  7,  hymen,  forming 
apex  of  posterior  triangle  ;  8,fourchette  ;  9,  fossa  navicularis  ;  10,  urethra; 
11,  bladder,  empty  and  relaxed  ;  12,  rectum  ;  13,  anus  ;  14,  recto-vaginal 
septum  ;  15,  perineum  ;  16,  vesico-uterine  fossa  of  peritoneum  ;  17,  pouch 
of  Douglas  ;  18,  os  pubis  ;  19,  labium  minus  ;  20,  labium  majus. 


is  free  to  yield  to  this  traction  and  is  accordingly  drawn  upward, 
so  that  the  upper  part  of  the  bladder  is  elevated  above  the  pubes 
(see  Fig.  131,  p.  220),  and  the  peritoneum  is  stripped  off  it.  Before 
the  commencement  of  labour,  the  whole  of  the  bladder,  when 
empty,  is  below  the  level  of  the  top  of  the  pubes.  When  the  anterior 
triangle  has  been  drawn  upward,  the  lower  part  of  the  bladder 
lies  behind  the  pubes,  flattened  by  pressure  of  the  presenting 
part.  The  urine,  if  any,  is  contained  in  the  upper  part  above 
the  level  of  the  top  of  the  pubes.  The  anterior  margin  of  the  os 
externum  {oe,  Fig.  132,  p.  221)  becomes  higher  in  reference  to  the 
plane  of  the  brim  than  the  posterior  margin.     The  anterior  margin 


Labour.  225 

of  the  OS  internum  or  retraction  ring,  whichever  be  the  correct 
interpretation  (oi,  Fig.  132),  is  also  elevated  as  much  as  1*8  inches 
higher  above  the  plane  of  the  brim  than  the  posterior  margin.  If 
the  ridge  indicated  at  C  be  the  true  internal  os,  its  anterior  margin 
lies  above  the  pelvic  brim,  while  its  posterior  margin  is  below  it, 
opposite  the  centre  of  the  second  piece  of  the  sacrum.  The  longi- 
tudinal tension  has  also  the  effect  that  the  cervix  and  lower  uterine 
segment  are  elongated  as  well  as  expanded  laterally,  and  their  walls 
are  thereby  the  more  thinned.-^  Since  the  posterior  pelvic  triangle 
cannot  be  drawn  upwards  as  a  whole,  but,  on  the  contrary,  is  driven 
downwards  by  the  advancing  head  (see  Fig.  131,  p.  220),  the  posterior 
wall  of  the  uterus,  especially  of  the  cervix,  is  more  thinned  than 
the  anterior.  Hence  arises  the  greater  liability  to  rupture  at  the 
posterior  wall.  In  proportion  as  the  wall  of  the  uterus  below 
the  retraction  ring  becomes  thinned  by  stretching,  longitudinal 
and  transverse,  so  the  wall  above  it  becomes  thickened  by  retraction 
or  shrinking,  chiefly  longitudinal. 

Caput  Succedaneum  in  the  First  Stage. — If  the  membranes 
are  ruptured  before  the  os  is  fully  dilated,  and  especially  if  the 
dilatation  is  long  deferred  and  the  pains  active,  an  effusion  of 
serum  takes  place  beneath  that  part  of  the  scalp,  or  other 
presenting  part  of  the  foetus,  which  projects  into  the  os,  and  so 
is  unsupported,  in  consequence  of  the  pressure  to  which  all  the 
rest  of  the  foetus  is  subjected.  In  addition  to  the  serum  a  small 
quantity  of  blood  may  also  be  effused.  The  swelling  thus  produced 
is  called  the  caput  succedaneum,  and  it  may  form  a  prominence 
elevated  for  half  an  inch  or  more  above  the  surface  of  the  cranial 
bones.  It  renders  the  shape  of  the  head  more  sharply  conical, 
and  thus  better  adapted  for  the  wedge-like  action  of  dilating  the 

1  The  ridge  marked  oi  was  regarded  by  Braune  as  the  internal  os,  partly  on  account 
of  the  large  vein  at  that  level  seen  in  the  section.  This  would  agree  with  the  view  of 
Baudl  (see  p.  155)  as  regards  the  internal  os  and  retraction  ring.  But  the  majority  of 
authorities  now  regard  it  as  the  retraction  ring.  Its  existence  as  a  ridge  projecting 
Inwards  may,  however,  be  due  to  its  coinciding  with  the  depression  between  the  head 
and  body  of  the  foetus,  as  is  seen  in  Fig.  131.  On  the  anterior  wall  of  the  uterus,  where 
the  coincidence  does  not  exist,  the  ridge  is  not  seen  on  the  section  of  the  wall.  In  a 
frozen  section  by  Barbour  showing  the  second  stage  of  labour,  the  head  lying  slightly 
lower  than  in  Fig.  LSI,  the  upper  part  of  the  bladder  is  in  about  the  same  position,  but 
the  peritoneum  is  stripped  off  only  the  front  of  it,  the  utero- vesical  reflection  of  perito- 
neum lying  at  the  level  of  the  top  of  the  pubes.  This  is  in  favour  of  the  view  that  the 
ridge  marked  at  6' indicates  the  position  of  the  internal  os.  It  is  not  certain  that  the 
great  elevation  of  the  I'etraction  ring  or  os  internum  above  the  level  of  the  brim  shown 
in  Fig.  IP)]  is  to  be  regarded  as  a  usual  occurrence  in  normal  labour.  It  is  true  that  the 
pelvis  is  not  contracted,  but  the  membranes  are  still  intact  although  theos  is  fully  ex- 
panded, and  the  second  stage  of  labour  so  far  advanced,  that  the  head  is  resting  on  the 
pelvic  outlet.  Tjabour  may  have  been  prolonged,  thercfoi'e,  in  consequence  of  the 
failure  of  the  membranes  to  rupture  earlier. 

M.  15 


226 


The   Practice  of   Midwifery. 


cervix.  It  therefore  tends  to  compensate,  in  some  small  degree, 
for  the  loss  of  the  bag  of  membranes  as  a  dilator.  The  position  of 
the  caput  succedaneum  as  regards  the  foetus  will  be  considered 
hereafter  in  reference  to  the  mechanism  of  labour. 

Second  or  Expulsive  Stage. — As  soon  as  the  membranes 
are  ruptured,  if  the  os  has  reached  the  stage  of  full  dilatation,  or 
nearly  so,  the  character  of  the  pains  is  completely  altered.  This 
arises  from  two  causes :  first,  because  the  cavity  of  the  uterus  is 
diminished,  and  its  walls  thereby  rendered  thicker  and  their 
muscular  power  stronger;  secondly,  because  there  is  an  increase 
of  reflex  stimulus,  from  the  walls  of  the  uterus  coming  into  contact 
with  the  fcetus,  and  the  cervix  and  vagina  being  pressed  upon  by 


Fig.  135. — Tracing  of  the  uterine  pains  during  the  expulsive  efforts  of  the 
second  stage,  showing  the  effect  of  the  contractions  of  the  abdominal 
muscles,  superimposed  upon  the  contractions  of  the  uterus.^ 


the  hard  head  instead  of  the  elastic  bag  of  membranes.  Immedi- 
ately after  the  rupture  of  the  membranes,  the  uterus,  contracting 
round  the  foetus,  appears  to  take  a  rest  for  a  short  time.  Then 
the  pains  recur,  and  are  now  much  more  powerful  and  prolonged, 
each  pain  lasting  sometimes  a  minute  and  a  half,  or  two  minutes, 
instead  of  less  than  a  minute.  At  first  the  pains  are  often  at 
longer  intervals  than  those  of  the  latter  part  of  the  first  stage, 
and  the  pulse,  in  consequence,  becomes  quieter  between  the  pains. 
As  labour  advances  they  become  again  more  frequent,  and  as  the 
head  begins  to  press  upon  and  pass  through  the  vulva,  pains  often 
come  in  quick  succession,  with  hardly  any  perceptible  interval, 
until  the  head  is  born.  In  the  expulsive  stage,  not  only  are  the 
uterine  contractions  more  powerful,  but  the  woman  now  instinctively 
aids  them  by  the  expiratory  muscles,  which  act  as  they  do  in 
defecation.  These  bearing-down  efforts,  though  they  are  made 
instinctively,  are  to  some  extent  under  the  control  of  the  will.     In 

1  Schatz.  Arch.  f.  Gynak,  Vol.  III.,  Table  III.,  Curve  XL,  1872. 


Labour. 


227 


order  to  fix  the  pelvis  and  the  chest,  the  woman  involuntarily 
places  her  feet  against  some  support,  such  as  the  foot  of  the  bed, 
and  clutches  something  with  her  hands,  such  as  a  long  towel  tied 
to  the  foot  of  the  bed.  A  deep  breath  is  first  taken,  and  then  the 
glottis  is  closed,  and  all  the  expiratory  muscles  put  into  strong 
action.  The  abdominal  pressure  so  produced,  besides  its  own  direct 
mechanical  effect,  probably  stimulates  the  uterus  to  more  vigorous 
contraction  (Fig.  135).  In  consequence  of  this  action  of  the  auxiliary 
muscles,  the  character  of  the  cry  is  altered  in  the  expulsive  stage. 
There  is  no  longer  any  loud  crying-out  during  the  height  of  a  pain. 


Fig.  136. — Appearance  of  the  vertex  at  the  vulval  outlet. 

but  instead  of  this  the  breath  is  held,  and  the  silence  is  broken 
only  by  short  deep  expiratory  groans  in  the  intervals  between  the 
bearing-down  efforts.  As  the  pain  is  passing  off,  or  when  it  is  just 
commencing,  there  may  still  be  loud  crying-out. 

Although  the  contractions  of  the  uterus  are  more  violent  in  the 
second  stage,  they  are  often  less  distressing  than  the  pains  of  the 
first  stage.  The  woman  herself  feels  the  presence  of  a  solid  body 
to  be  expelled,  her  attention  is  taken  up  by  the  semi- voluntary 
efforts  which  she  makes  to  expel  it,  and  her  patience  is  no  longer 
tried  by  the  feeling  that  no  progress  is  being  made.  The  action 
of  the  respiratory  muscles  must  be  regarded  as  reflex  although 
partially  under  the  control   of   the  will.     For    the  bearing-down 

15—2 


228 


The  Practice  of   Midwifery. 


efforts  may  take  place  to  some  extent  mider  chloroform  narcosis,  if 
not  too  deep,  or  in  the  coma  following  puerperal  convulsions.  The 
auxiliary  forces  can  only  act  with  a  closed  glottis,  and  the  action 
of  the  glottis  has  been  well  compared  to  that  of  a  safety-valve.  As 
the  head  approaches  the  outlet  of  the  vagina,  which  is  the  most 
sensitive  part  of  the  canal,  and  where  there  is  most  risk  of  lacera- 
tion, the  pain  becomes  so  intense  at  the  height  of  a  contraction,  if 
a  rupture  is  threatened,  that  the  woman  opens  her  glottis  to  cry 
out.  The  effect  is  immediately  to  take  off  a  part  of  the  expulsive 
force,  and  so  diminish  the  risk  of  rupture.  Such  an  outcry  generally 
takes  place  when  the  head  is  just  on  the  point  of  passing,  and  the 


SS- 


FiG.  137. — Emergence  of  foetal  head  at  vulval  outlet.  2<S^,  second  sacral  ver- 
tebra :  B,  bladder  ;  B,  rectum  ;  a,  anus  ;  /,  fourchette  ;  u?;  urethra.  (After 
Schroeder.) 

perineum  and  vaginal  outlet  are  at  their  greatest  strain.  Besides 
the  safety-valve  action  of  the  glottis,  which  takes  place  automati- 
cally, the  accoucheur  may  also  utilise  it  to  some  extent  to  regulate 
the  course  of  labour.  If  the  pains  are  ineffective,  and  the  bearing- 
down  efforts  weak,  he  may  exhort  the  woman  to  hold  her  breath, 
and  make  stronger  efforts  ;  if,  on  the  other  hand,  the  pains  are 
violent  and  a  rupture  of  the  perineum  is  threatened,  he  may  tell 
her  to  cry  out,  and  not  to  hold  her  breath. 

Under  the  influence  of  the  pains  of  the  second  stage,  the  head 
advances  intermittently,  receding  somewhat  in  the  intervals  of 
the  pains  in  consequence  of  the  elasticity  of  the  soft  parts.  A 
caput  succedaneum  is  formed  more  frequently  in  the  expulsive 
stage  than  in  the  first  stage,  and  it  now  occupies  that  j)art  of  the 


Labour.  229 

head  which  loolis  in  the  direction  of  its  motion,  and  is  unsupported 
by  either  cervix  or  vaginal  walls,  being  due  as  before  to  the 
effect  of  pressure  upon  all  the  rest  of  the  foetus.  By  the  pressure 
of  the  head  as  it  descends,  the  rectum  is  emptied  of  any  fgeces 
which  it  may  contain.  As  the  head  begins  to  press  upon  and 
distend  the  perineal  body,  the  perineum  bulges  outward,  and  at  the 
same  time  it  is  elongated  and  its  anterior  margin  carried  forward. 
The  rectum  is  flattened  by  the  head  ;  the  anus  itself  is  carried 
forward,  lengthening  the  space  between  it  and  the  coccyx,  and,  as 
the  apex  of  the  head  protrudes  through  the  vulva,  the  stretching 
of  the  perineum  drags  apart  the  margin  of  the  anus,  and  the  anus 
opens  to  the  size  of  an  inch  or  more  in  the  shape  of  a  D,  the 
anterior  wall  of  the  rectum  resting  upon  it  (see  Fig.  136,  p.  227). 
Tearing  of  the  mucous  membrane  covering  the  anterior  wall  of  the 
rectum  not  uncommonly  occurs,  and  may  give  rise  to  smart  bleed- 
ing. Eventually  the  edge  of  the  perineum,  stretched  almost  as  thin 
as  a  membrane,  forms  a  ring  round  the  apex  of  the  head,  if  it  has 
not  been  lacerated  in  a  previous  labour.  The  perineum  may  be  so 
thin  toward  its  anterior  part,  that  the  sutures  of  the  head  can  be 
felt  through  it  (Fig.  137,  p.  228).  Before  this  can  take  place  in  a 
primipara,  the  inevitable  laceration  at  the  posterior  part  of  the 
vaginal  outlet,  marked  by  the  insertion  of  the  hymen,  must  have 
already  occurred.  By  alternate  advance  and  recession  of  the  head, 
the  thin  margin  of  the  perineum  is  gradually  stretched.  Sometimes 
the  head  is  arrested  at  the  end  of  a  pain,  with  the  thin  ring  still 
stretched  over  it  and  intact,  but  no  longer  recedes.  This  has  been 
called  the  stage  of  "  crowning,"  and  when  it  occurs,  may  generally 
be  taken  as  a  sign  that  the  head  will  pass  without  any  serious 
laceration  of  perineum.  As  soon  as  the  greatest  diameter  of  the 
head  has  passed,  the  elastic  and  contractile  forces  of  the  vagina 
assist  its  further  progress,  and  the  edge  of  the  perineum  quickly 
slips  over  it.  Slight  laceration  of  the  fourchette  at  this  time  is  very 
common,  but  not  inevitable.  The  body  is  sometimes  expelled^^by 
the  same  pain,  and  generally  by,  at  any  rate,  the  following  one, 
which  occurs  after  a  short  interval  of  rest,  and  is  followed  by  a  gush 
of  pent-up  liquor  amnii,  at  times  mingled  with  some  blood  which 
indicates  partial  detachment  of  the  placenta.  Thus  terminates  the 
second  stage  of  labour.  The  description  of  the  third  stage  will  be 
deferred  till  after  the  consideration  of  the  mechanism  of  the  second 
staf'e. 


Chapter  XII. 
THE  MECHANISM  OF  LABOUR. 

The  manner  in  which  the  foetal  head  passes  through  the  genital 
canal  depends  upon  the  propulsive  forces  which  act  upon  it,  and 
the  resistance  which  it  meets.  In  order,  therefore,  to  understand 
the  mechanism  of  labour  in  head  presentations,  and  the  various 
movements  of  the  head  during  its  passage,  it  is  necessary,  in  the 
first  place,  to  study  the  forces  which  act  upon  the  fcetus,  and  the 
direction  of  action  of  each. 

The  propulsive  force  produced  by  a  uterine  contraction  is  made 
uj)  of  two  parts — (1)  the  general  intra-uterine  jiressure,  (2)  the  direct 
uterine  pressure  upon  the  fcetus. 

General  Intra-uterine  Pressure. — The  contracting  walls  of  the 
uterus  pressing  upon  the  bag  of  membranes  in  its  cavity,  filled  with 
liquor  amnii,  cause  a  j^ressure  in  that  fluid  which,  in  general,  is 
uniform  throughout  every  part  of  it,  with  the  exception  of  the 
variation  at  different  levels,  due  to  the  weight  of  the  fluid  itself.  So 
long  as  the  cervix  uteri  is  closed  no  propulsive  force  is  thus  pro- 
duced. As  soon  as  the  cervix  begins  to  be  opened,  the  pressure  in 
the  liquor  amnii  causes  the  bag  of  membranes  to  bulge  through  the 
OS.  A  resultant  propulsive  force  is  then  produced  which  tends  to 
force  the  ovum  as  a  whole  forwards  through  the  cervix,  but  has  no 
action  upon  the  foetus.  Its  direction  may  be  inferred  from  the 
consideration  that  it  would  be  neutralised  if  there  were  no  unsup- 
ported part  of  the  bag  of  membranes,  that  is  to  say,  if  there  were 
an  equal  pressure  acting  over  every  part  of  the  membranes  which 
bulge  into  the  os.  The  force  must  therefore  be  equal  and  opposite 
to  that  which  would  be  the  resultant  of  such  a  uniform  pressure 
over  the  bulging  membranes  ;  in  other  words,  it  acts  in  the  central 
axis  of  the  os  uteri  and  perpendicular  to  its  plane.  If  the  mem- 
branes still  remain  unruptured  after  the  os  uteri  is  fully  dilated,  as 
in  such  a  case  as  that  shown  in  Fig.  131,  p.  220,  we  must  conceive 
the  place  of  the  os  uteri  to  be  taken  by  that  circle  of  the  vagina 
where  the  bag  of  membranes  ceases  to  be  pressed  upon  by  the 
vaginal  walls,  and  becomes  unsupported  (Fig.  131). 

After  the  rupture  of  the  membranes,  the  head  usually  fills  up  the 


The   Mechanism   of   Labour. 


231 


cervix  uteri  or  vagina  like  a  ball  valve,  and  a  considerable  propor- 
tion of  the  liquor  amnii  is  retained  within  the  cavity  of  the  uterus, 
although  a  small  quantity  of  it  generally  continues  to  escape  at 
the  commencement  of  each  pain  throughout  the  course  of  labour. 
The  general  intra-uterine  pressure  then  acts  on  the  upper  surface 
of  the  head,  while  that  part  which  projects  into  the  os  uteri  or 
vagina  is  unsupported.  The  force  acting  on  the  head  from  this 
cause  is  equivalent  to  a  fluid  pressure  equal  to  that  of  the  liquor 
amnii  acting  on  the  upper  surface 

of  the  head,  including  that  part  . ----^ 

which  is  articulated  to  the  trunk. 
The  reason  of  this  is  that  the 
trunk  would  be  in  equilibrium, 
as  far  as  regards  the  liquor 
amnii,  if  a  surface  of  similar 
fluid  pressure  were  substituted 
for  the  area  of  junction  with  the 
head ;  and  therefore  the  effect 
of  the  fluid  pressure  transmitted 
from  the  trunk  to  the  head  is  the 
same  as  if  the  trunk  were 
removed  and  the  fluid  acted 
directly  on  the  head.  Thus 
results  a  propulsive  force,  acting 
no  longer  upon  the  whole  ovum, 
but  upon  the  head.  It  is  not 
transmitted  to  the  head  through 
the  condyles,  but,  in  analogy 
with  the  former  case,  its  direc- 
tion is  perpendicular  to  that 
circle   of    the    head    where  the 

head  ceases  to  be  pressed  upon  by  the  cervix  or  vagina,  as  the  case 
may  be,  and  lies  in  the  central  axis  of  that  circle. 

In  general  there  is  free  communication  between  the  liquor  amnii 
within  the  uterus  and  that  in  the  bulging  bag  of  membranes  in 
front  of  the  head,  sometimes  called  the  "  fore-waters."  During  a 
pain  the  bulging  of  the  membranes  is  increased  and  the  head 
appears  to  recede.  So  long  as  this  is  the  case,  the  general  intra- 
uterine pressure  does  not  exercise  any  propulsive  force  upon  the 
ffx'tus  until  after  rupture  of  the  membranes.  There  is  one  excep- 
tion, liowever,  to  this  rule.  Sometimes,  when  the  liquor  amnii  is 
scanty,  and  the  expulsive  stage  of  labour  progresses  with  the 
membranes  still  unruptured,  as  shown  in  Fig.  131,  p.  220,  the  head. 


FiGr.  138. — Diagram  of  general  intra- 
uterine pressure  showing  bulging  of 
bag  of  membranes  through  the  os. 


232 


The   Practice  of   Midwifery. 


may  fit  so  tightly  in  the  genital  canal  as  to  shut  off  the  fore-waters 
from  the  liquor  amnii  within  the  uterus.  The  increased  intra- 
uterine pressure  due  to  a  pain  is  then  not  transmitted  to  the 
fore-waters  and  exercises  a  propulsive  force  on  the  foetus,  due  to 
the  excess  of  the  intra-uterine  pressure  over  that  of  the  fore-waters. 
It  is  to  be  noted  that  in  Barbour's  frozen  section,  representing 
the  second  stage  of  labour,  the  head  near  the  outlet,  liquor  amnii 


Fig.  139. — Diagram  of  the  parturient  canal  in  a  state  of  full  dilatation. 


intervenes  between  the  breech   and  the  fundus  uteri.     The  chief 
force  at  work  is  therefore  the  general  intra-uterine  pressure. 

Direct  Uterine  Pressure. — Besides  the  pressure  transmitted 
through  the  liquor  amnii,  the  uterine  walls  exercise  direct  pressure 
on  the  body  and  limbs  of  the  foetus  where  they  come  in  contact, 
and  thus  produce  a  force  which  is  transmitted  to  the  head  through 
the  foetal  spine  and  the  occipital  condyles.  If  the  uterus  were  to 
contract  like  a  uniform  bag,  it  would  tend,  during  a  pain,  to 
assume  a  spherical  shape,  the  sphere  being  that  form  which  has 


The   Mechanism  of   Labour. 


233 


the  smallest  surface  for  a  given  amount  of  cubic  contents.  This  is 
not  found  to  be  the  case.  When  uncontracted,  the  uterus  lies 
like  a  more  or  less  flaccid  bag  moulded  upon  the  surrounding 
structures ;  but,  when  it  contracts,  it  tends  to  assume  a  certain 
definite  form,  dependent  upon  its  natural  shape,  and  the  relative 
strength  of  its  muscular  fibres.  Hence,  by  German  authors,  this 
direct  uterine  pressure  upon  the  foetus  is  called  the  "  form-restitu- 
tion force."     During  a  pain  a  transverse  section  of  the   uterus, 


Fig.  140. — Sagittal  section  of  primipara  at  beginning  of  first  stage  of  labour. 
Commencing  dilatation  of  cervical  canal.  Note  shape  of  uterus  and 
level  of  fundus  as  compared  with  Fig.  141.1 


which,  when  the  woman  is  lying  on  her  back,  is  much  flattened 
antero-posteriorly  from  the  effect  of  gravity,  becomes  more  nearly 
circular.  The  longitudinal  diameter  of  the  uterus  is  found  to  be  not 
shortened,  but  actually  lengthened,  during  a  pain,  while  the  antero- 
posterior diameter  is  shortened  relatively  to  the  transverse.  This 
proves  that  the  action  of  the  circular  fibres  is  relatively  so  powerful 
that  the  axis  of  the  ffXitus  is  straightened  by  the  pain,  notwithstanding 
the  pressure  on  the  l)reech  (Fig.  141).  Actually,  owing  to  the  extension 

'    l,fo|,(.l(|,  uterus  mill  Kind,  Plate  XVlll. 


234 


The  Practice  of   Midwifery. 


of  the  head  and  of  the  spine  of  the  foetus,  its  length  from  the  vertex 
to  the  breech  is  usually  increased  from  about  10  inches  (25  cm.)  to 
14  inches  (35  cm.)  (see  Fig.  141).  And  thus  is  explained  the  fact  that 
the  pressure  on  the  breech,  due  to  the  action  of  the  longitudinal  fibres, 
is  able  to  transmit  a  force  through  the  spine  to  the  head  without 
loss,  notwithstanding  the  pliant  nature  of  the  foetal  axis,  that  axis 


Fig.  141. — Sagittal  section  in  outline  of  Barbour's  uterus  from  near  end  of 
second  stage  of  labour.  Note  shape  of  uterus  and  level  of  fundus  as 
compared  with  Fig.  140. 

being  supported  on  all  sides  by  the  circular  fibres  and  so  prevented 
from  bending. 

The  direction  of  the  force  resulting  from  the  direct  uterine 
pressure  on  the  foetus  is.  approximately  parallel  to  the  axis  of  the 
uterus.  The  direction  of  the  axis  of  the  uterus  during  labour  is 
generally  considered  to  be  normally  nearly  coincident  with  the  axis 
of  the  pelvic  brim,  but  varies  to  some  extent  either  in  consequence  of 
the  common  deviation  of  the  fundus  uteri  toward  the  right  side,  or  in 
accordance  with  the  position  of  the  woman  (Fig.  140).  In  the  absence 
of  a  pain,  while  the  woman  is  lying  on  her  back,  the  fundus  uteri  is 
inclined  backward  in  reference  to  the  axis  of  the  brim,  a  position 


The   Mechanism  of   Labour.  235 

which  is  seen  also  in  the  frozen  corpse  (Fig.  131,  p.  220) ;  but  during 
a  pain,  in  the  second  stage  of  labour,  the  fundus  becomes  more  or 
less  thrown  forward,  in  consequence  of  the  descent  of  the  diaphragm 
produced  by  the  preliminary  deep  inspiration,  and  by  the  drag  pro- 
duced by  the  contracting  round  ligaments.  When  the  woman 
stands  upright,  on  the  other  hand,  the  fundus  is  apt  to  be  inclined 
forward  in  reference  to  the  axis  of  the  brim,  if  the  abdominal  walls 
are  lax.  On  the  whole,  the  average  direction  of  the  axis  of  the 
uterus  may  be  regarded  as  being  slightly  inclined  posteriorly  in 
reference  to  the  axis  of  the  brim  (see  Fig.  139,  p.  232).  This 
implies  a  corresponding  inclination  of  the  force  due  to  direct  uterine 
pressure.  Fig.  139  is  diagrammatic,  since  the  whole  parturient 
canal  is  not  dilated  thus  at  the  same  time,  the  fundus  having 
begun  to  descend  by  retraction  before  the  vulval  outlet  is  fully 
dilated  by  the  advancing  head. 

Auxiliary  Forces. — In  the  expulsive  stage  of  labour,  when  the 
auxiliary  muscles  come  to  the  aid  of  the  uterus,  the  first  step  is 
that,  at  the  onset  of  a  pain,  the  woman  takes  a  deep  breath  and 
then  closes  the  glottis,  thus  fixing  the  diaphragm.  This  descent  of 
the  diaphragm  depresses  somewhat  the  fundus  uteri,  and  thus 
brings  the  uterine  axis  more  nearly  into  coincidence  with  the  axis 
of  the  brim.  The  glottis  remaining  closed,  the  expiratory  muscles 
of  the  abdomen  and  chest  compress  the  abdominal  contents,  just 
as  in  defecation  or  micturition,  while  the  diaphragm  remains  passive. 
The  abdominal  pressure  thus  produced  acts  over  every  part  of  the 
outside  of  the  uterus  except  those  which  are  below  the  level  of  the 
stratum  of  cellular  tissue  in  the  pelvis  forming  the  floor  of  the 
abdominal  cavity.  The  part  of  the  uterus  thus  pressed  upon 
coincides  nearly  with  that  part  of  the  muscle  which  is  actively  con- 
tracting. The  effect  of  the  auxiliary  muscles  is  therefore  to  add  to 
each  of  the  resultant  forces  already  mentioned,  namely,  the  general 
intra-uterine  pressure,  and  the  direct  uterine  pressure  on  the  fcetus. 
It  has  also  another  influence  of  great  practical  value,  namely,  that 
it  tends  to  press  the  uterus  downwards,  as  a  whole,  towards  the 
pelvis.  This  takes  off  the  tension  placed  by  the  uterine  contrac- 
tions on  that  lower  distensible  uterine  segment  which  intervenes 
between  the  strong  retracting  or  thickening  part  of  the  muscle  (see 
p.  15G),  and  the  attachment  of  the  uterus  to  the  pelvis,  and  which 
accordingly  is  the  part  of  the  uterus  most  liable  to  rupture.  Thus 
the  tendency  to  rupture  of  the  uterus  is  resisted  by  an  efficient 
action  of  the  auxiliary  muscles,  and  is  more  likely  to  occur  if  the 
aljdominal  walls  are  weakened  by  fat  or  over-distension. 


236 


The   Practice  of   Midwifery. 


In  a  protracted  labour,  as  the  liquor  amnii  gradually  escapes 
more  and  more  completely,  the  uterine  walls  come  into  closer 
contact  with  the  foetus,  and  thus  the  relative  importance  of  the 
general  intra-uterine  pressure  becomes  progressively  less,  and  that 
of  the  direct  uterine  pressure  on  the  foetus  progressively  greater. 
This  will  happen  the  more  rapidly  if  any  deformity  of  the  pelvis 
prevents  the  head  descending  into  it  sufficiently  to  act  effectively 


Fig.  142. — Section  of  uterus  with  child  i/i  situ,  towards  the  end  of  the  second 
stage  of  labour.  The  membranes  have  ruptured,  the  head  lying  between 
the  right  oblique,  and  the  conjugate  diameter  is  at  the  vulva,  and  there 
is  a  well-marked  caput  succedaneum.  There  is  some  undoing  of  the 
flexion  of  the  spinal  column,  and  there  is  a  space  between  the  arms  and 
the  legs.i 


as  a  ball-valve.  It  will  be  observed  that  the  force  exerted  by  the 
general  intra-uterine  pressure  on  the  head  is  always  perpendicular 
to  that  circle  of  the  soft  parts  which  the  head  is  at  the  moment 
entering,  and  therefore  acts  always  at  the  greatest  possible  advan- 
tage. That  produced  by  the  direct  uterine  pressure  acts  nearly  in 
the  axis  of  the  brim  until  the  head  is  so  far  advanced  that  the  trunk 
meets   the   inclined   pelvic   floor  (see  Fig.  137,  p.  228).     It  then 

1  From  Barbour,  Atlas  of  the  Anatomy  of  Labour,  Plate  XXII. 


The   Mechanism  of   Labour. 


237 


becomes  inclined  more  forward,  but  still  does  not  act  so  strictly  in 
the  direction  in  which  the  head  is  advancing  as  the  other  force.  It 
is  therefore  an  advantage  if,  in  the  later  stage  of  labour,  a  consider- 
able quantity  of  liquor  amnii  is  still  retained. 

Magnitude  of  the  Forces  acting  in  Labour. — The  force  exerted 
by  the  uterus  is  of  much  greater  magnitude  and  importance  than 
that  produced  by  the  auxiliary  muscles.  This  is  proved  by  the 
fact  that,  if  pains  are  absent,  no  voluntary  effort  is  effective  in  for- 
warding labour.  Matthews  Duncan^  ascertained  experimentally  the 
force  necessary  to  rupture  the  membranes,  and  found  it  to  vary 


Fig.  143. — Superficial  and  deep  muscles  of  pelvic  floor  seen  from  below. 

from  4^  to  36  lb.,  the  average  being  15  lb.  He  inferred  that  the 
minimum  force  necessary  to  complete  labour  does  not  much  exceed 
that  which  ruptures  the  membranes,  and  believed  that  the  force 
naturally  expended  does  not  often  exceed  50  lb.  Schatz^  endeavoured 
to  measure  the  force  directly  by  manometer,  and  found  that  in 
normal  conditions  during  the  pains  the  intra-uterine  pressure  was 
indicated  by  a  column  of  mercury  80  mm.  in  height,  represent- 
ing a  force  of  some  8  to  9  kilos.,  18  to  20  lb.,  or  in  some  cases  by  a 
column  200  mm.  high  or  a  force  of  25  to  30  kilos.,  55  to  66  lb. 

The  natural  rupture  of  the  membranes  at  a  certain  time,  which 
normally  should  correspond  to  the  completion  of  the  first  stage, 

'   Ilesea  relies  in  OVjstetrics,  p.  299. 

-  Scliatz,  Verliandlunj(en  d.  Deutschen  Gesell.  f.  Oyii.,  1X95,  VL,  |i.  5;5I. 


238 


The  Practice  of   Midwifery. 


depends  upon  two  factors,  first  the  increase  in  size  of  the  os  uteri, 
and,  secondly,  the  progressive  increase  in  the  force  of  the  pains. 
Supposing  the  pressure  of  the  Hquor  amnii  to  remain  constant,  the 
effect  of  that  pressure  in  producing  tension,  and  therefore  tendency 
to  rupture,  of  the  enclosing  membrane,  is  proportional  to  the  radius 
of  that  sphere  which  corresponds  incurvature  to  the  projecting  bag 
of  membranes  at  any  point.  While  the  os  is  still  small,  the  pro- 
truding membranes  form  a  segment  of  a  small  sphere,  but  as  the 
OS  enlarges,  the  corresponding  sphere  also  enlarges,  and  with  it  the 
strain  upon  the  membranes,  even  apart  from  any  increased  vigour 
in  the  pains. 


Fig.  144. — Lateral  view  of   muscles  of   pelvic    floor.       (After  Farabeuf  and 
Varnier,  Introduction  al'etude  clinique  et  a  la  Pratique  des  accouchements.) 


Resistances. — The  movements  of  the  head  and  other  parts  of  the 
foetus  in  passing  through  the  pelvis  are  determined  by  the  directions 
of  the  resistances  they  encounter.  It  has  already  been  explained 
(see  p.  18)  that  the  pelvis  is  so  shaped  that  it  corresponds,  in  a 
degree,  to  a  female  screw.  The  largest  diameter  gradually  changes 
from  a  transverse  to  an  antero-posterior  direction,  as  it  is  traced 
from  above  downwards,  and  the  anterior  and  posterior  inclined 
planes  of  the  ischium  are  so  arranged  that  the  left  anterior  and 
right  posterior  quarters  of  the  pelvis  combine  to  form  a  portion  of 
a  screw  with  a  turn  from  left  to  right ;  the  right  anterior  and  left 
posterior  quarters  another  portion  of  screw  with  the  opposite  turn, 
namely  from  right  to  left.  When  the  head  reaches  the  floor  of  the 
pelvis  it  meets  an  inclined  plane  sloping  forwards,  formed,  first,  by 
the  lower  part  of  the  sacrum,  secondly  by  the  coccyx  with  the 
muscles  attached  to  it,  thirdly  by  the  soft  parts  between  the  coccyx 


The   Mechanism  of   Labour.  239 

and  the  anus,  together  with  the  recto-vaginal  septum  which  lies 
flattened  against  them,  and  finally  by  the  perineal  body.  This 
inclined  plane,  as  it  exists  in  a  multipara  when  the  vaginal  canal  is 
as  yet  only  partially  dilated,  is  well  seen  in  the  section  from  a 
frozen  body,  shown  in  Fig.  131,  p.  220.  In  a  primipara,  the  perineal 
body  extends  much  further  forward,  and  its  position,  when  fully 
distended  by  the  advancing  head,  is  shown  in  Fig.  139,  p.  232. 

The  movement  of  the  presenting  part,  as  it  approaches  the 
outlet  of  the  soft  parts,  is  much  affected  by  the  shape  of  the 
strong  muscle  which  virtually  forms  the  sphincter  of  the  vagina, 
namely  the  anterior  portion  of  the  levator  ani  (Fig.  143).  The 
main  attachments  of  this  important  muscle,  which,  together 
with  the  coccygeus  muscle  and  the  pelvic  fascia,  makes  up  the 
pelvic  floor,  are  as  follows.  Arising  from  the  posterior  surface 
of  the  pubes  from  the  white  line  on  the  obturator  fascia,  and 
from  the  ischial  spine,  it  passes  back,  surrounding  the  vagina 
and  the  rectum,  to  be  attached  to  the  side  of  the  coccyx,  to  the 
raphe  between  that  bone  and  the  anus,  to  the  sides  of  the  rectum 
and  vagina,  and  to  the  perineal  body.  Hence,  when  the  pelvic 
floor,  driven  down  before  the  advancing  foetus,  is  bulged  outward, 
and  the  anterior  portion  of  the  levator  ani  stretched  open,  this 
muscle  being  attached  most  firmly  anteriorly  and  posteriorly  and 
comparatively  free  at  the  sides,  takes  the  form  of  an  ellipse,  with 
its  long  diameter  antero-posterior.  In  easy  labours,  when  the 
presenting  part  does  not  fit  tightly  to  the  bony  pelvis,  the  shape  of 
this  elliptic  opening  has  more  to  do  than  that  of  the  pelvis  with 
the  rotation  of  the  long  diameters  of  the  presenting  part  into  the 
antero-posterior  diameter  of  the  outlet. 


Positions  of  the  Head  in  Vertex  Presentations. 

The  head,  as  it  enters  the  brim,  may  occupy  almost  any  diameter 
of  the  pelvis.  The  simplest  classification  is  that  adopted  by 
British  authors,  according  to  which  the  pelvis  is  divided  into  four 
quadrants  by  antero-posterior  and  transverse  lines,  and  four 
positions  of  the  head  are  described  according  to  the  quadrant  in 
which  the  occiput  lies.  For  any  other  presenting  part  there  will 
also  be  four  corresponding  positions.  Again,  it  is  usual  with 
British  authors  to  name  the  right  oblique  diameter  of  the  pelvis 
that  diameter  which  passes  through  the  right  sacro-iliac  articu- 
lation, and  the  left  oblique  that  which  passes  through  the  left 
sacro-iliac  articulation.  It  must  be  borne  in  mind,  that  by  some 
Continental  writers  exactly  the  reverse  usage  is  adopted. 


240 


The   Practice  of   Midwifery. 


The  four  following  are  the  positions  of  the  foetal  head  : — 
First  or  left  occijnto-anterior  (L.  0.  A.). — The  long  diameter  of 
the  head  approximates  toward  the  right  oblique  diameter  of  the 


Fia.  145.— Brim  of  the  pelvis,  and  base  of  the  foetal  skull  in  the 
first  cranial  position. 

pelvis.  The  occiput  points  toward  the  left  foramen  ovale ;  the 
forehead  toward  the  right  sacro-iliac  articulation. 

Second  or  right  occipito-anterior  {R.  0.  A.). — The  long  diameter  of 
the  head  approximates  toward  the  left  oblique  diameter  of  the 
pelvis.  The  occiput  points  toward  the  right  foramen  ovale  ;  the 
forehead  toward  the  left  sacro-iliac  articulation. 

Third  or  right  occijnto-posterior  {R.  0.  P.). — The  long  diameter 


Fig.  146. — Brim  of  the  pelvis,  and  base  of  the  foetal  skull  in  the  second  position. 

of  the  head  approximates  toward  the  right  oblique  diameter  of  the 
pelvis.  The  occiput  points  toward  the  right  sacro-iliac  articulation  ; 
the  forehead  toward  the  left  foramen  ovale. 

Fourth  or  left  occipito-posterior  (L.  0.  P.). — The  long  diameter  of 
the  head  approximates  toward   the   left  oblique  diameter  of  the 


The   Mechanism  of  Labour. 


241 


pelvis.     The  occiput  points  toward  the  left  sacro-iliac  articulation  ; 
the  forehead  toward  the  right  foramen  ovale. 

It  is  not  meant  that  in  these  positions  the  long  diameter  of  the 
head  lies  precisely  in  any  oblique  diameter  of  the  pelvis,. for,  as  a 


Fig.  1J:7. — Brim  of  the  pelvis,  and  base  of  the  fcetal  skull  in  the  third  position. 

rule,  it  is  more  nearly  transverse  than  antero-posterior,  but  only 
that  it  approximates  more  nearly  to  that  oblique  diameter  than  to 
any  other.  If  the  long  diameter  of  the  head  is  exactly  transverse, 
it  is  regarded  as  being  on  the  boundary  between  the  first  and 
fourth  ;  or  between  the  second  and  third  positions  ;  if  it  is  exactly 


Fig.  148. — Brim  of  the  pelvis,  and  base  of  the  foetal  skull  in  the  fourth  position. 

antero-posterior  (which  can  only  happen  in  a  transversely  con- 
tracted brim),  it  is  regarded  as  being  on  the  boundary  between 
the  first  and  second  or  between  the  third  and  fourth. 

These  four  positions  of  the  vertex,  or  of  any  other  presenting 
part,  such  as  the  face  or  breech,  can  at  once  be  deduced  if  the 
following  two  facts  are  remembered — first,  that  the  back  of  the 
child  looks  forward  in  the  first  and  second  positions,  backward  in 

M.  16 


242 


The   Practice  of   Midwifery. 


the  third  and  fourth ;  secondly,  that  its  antero-posterior  diameter 
lies  in  the  right  oblique  diameter  of  the  pelvis  in  the  first  and 
third  positions,  in  the  left  oblique  diameter  in  the  second  and 
fourth.  It  should  also  be  remembered  that  the  back  of  the  child 
is  to  the  mother's  left  in  the  first  and  fourth,  to  her  right  in  the 
second  and  third  positions. 

It  has  been  mentioned  (see  p.  18),  that,  at  the  pelvic  brim,  the 
transverse  diameter  is  the  largest.  The  reason  why  the  long 
diameter    of    the    head    generally    enters   the    pelvis    somewhat 


Fig.  149.  —  First    vertex     presentation,    left         FiG.   150.— Second   vertex   presentation,   right 
occipito    anterior.     Head  markedly   flexed.  occipito  anterior.    Plead  markedly  flexed. 


obliquely,  and  not  in  the  transverse  diameter,  is  twofold.  First, 
the  psoas  and  iliacus  muscles  so  reduce  the  transverse  diameter 
at  the  brim  that,  in  the  pelvis  clothed  with  its  soft  parts,  the 
transverse  diameter  is  not  greater  than  the  oblique.  Secondly, 
the  initial  position  of  the  head  is  greatly  influenced  by  the  position 
of  the  body  of  the  child  before  the  onset  of  labour.  The  child 
generally  lies  in  the  uterus  with  its  back  directed  somewhat 
forward.  The  main  reason  for  this  is  that  the  posterior  wall  of 
the  uterus  is  rendered  somewhat  convex  inwardly  by  the  projec- 
tion of  the  lumbar  vertebrse  of  the  mother  (see  Fig.  131,  p.  220, 
and  Fig.  139,  p.  232).     The  foetus  is  therefore  better  accommodated 


The  Mechanism  of   Labour. 


243 


to  the  shape  of  the  uterus  when  the  fcetal  spine  is  turned  away 
from  the  spine  of  the  mother. 

If  the  conjugate  diameter  of  the  pelvic  brim  is  contracted, 
while  the  transverse  is  relatively  large,  the  long  diameter  of  the 
head  enters  the  brim  almost  exactly  in  the  transverse  diameter. 
In  the  much  more  rare  cases  in  which  the  pelvis  is  contracted 
transversely  at  the  brim,  to  such  an  extent  that  its  antero- 
posterior diameter  is  the  largest,  the  long  diameter  of  the  head 
may   enter   the   brim   nearly   in   that   antero-posterior   diameter, 


Fig.  151. — Third  vertex  presentation,  riglit 
occipito  posterior.  Flexion  of  head  not  so 
marked  as  in  occipito  anterior  presenta- 
tion. 


Fig-.  152. — Fourth  vertex  presentation,  left 
occipito  posterior.  Flexion  of  head  not  so 
marked  as  in  occipito  anterior  presenta- 
tion.i 


provided    that    there    is    insufficient   room    for   it    in   the   other 
diameters. 

The  proportion  of  cases  in  which  the  vertex  presents  is  more 
than  96  per  cent.  In  about  24,000  deliveries  in  Guy's  Hospital 
Lying-in  Charity  it  was  96"9  per  cent.  As  to  the  relative  frequency 
of  the  different  positions  of  the  vertex,  very  various  estimates 
are  given.  Without  any  doubt  the  first  position  is  much  the 
commonest,  and  its  frequency  is  variously  given  as  from  65  to  80 
per  cent,  of  vertex  presentations.  Almost  all  authorities  also  agree 
that  the  fourth  position  is  much  the  rarest,  and,  according  to  the 

1  The  four  figures,  149,  1.50,  151,  152,  all  from  Farabeiif  and  Varnier,  Pratique  des 
Accouchements,  Figs.  31,  '62,  33  and  34, 

16—2 


244  The   Practice  of   Midwifery. 

highest  estimate,  its  frequency  is  less  than  5  per  cent.,  or  about 
2*6  per  cent.  The  chief  difference  of  opinion  is  as  to  the  relative 
frequency  of  second  and  third  positions.  The  cause  of  the  dis- 
crepancy is  partly,  that  third  positions  generally  change  into  second, 
and  that  the  case  may  be  observed  for  the  first  time  either  before 
or  after  the  change  ;  part,]y  that,  when  the  back  of  the  foetus  is 
toward  the  right,  the  long  axis  of  the  head  is  often  so  nearly 
transverse  that  it  is  difficult  to  say  whether  the  position  should  be 
called  second  or  third. 

It  was  taught  by  Naegele  that,  in  99  per  cent,  of  all  cases,  the 
long  diameter  of  the  head  lay  at  first  in  the  right  oblique  diameter 
of  the  pelvis,  and  that  second  positions,  as  well  as  fourth,  were 
excessively  rare.  The  opinion  of  many  modern  authorities  is 
rather  that  primary  second  positions  are  about  as  common  as 
third,  so  that  the  frequency  of  each  may  be  taken  as  about 
15  per  cent. 

The  chief  reason  why  the  long  diameter  of  the  head  so 
frequently  lies  in  the  right  oblique  diameter  of  the  pelvis  is  that 
the  left  oblique  diameter  of  the  pelvis  and  lower  part  of  abdomen 
is  partially  occupied  by  the  rectum  and  sigmoid  flexure,  with  their 
contents,  and  so  affords  less  space.  Another  cause  also  contributes 
to  the  great  frequency  of  the  first  or  left  occipito-anterior  position. 
The  pregnant  uterus  generall}^  not  only  has  a  natural  obliquity 
toward  the  right  side,  but  is  rotated  somewhat  on  its  axis,  so  that 
its  front  looks  toAvard  the  right,  and  its  left  side  is  foremost.  The 
left  and  anterior  portion  of  the  uterus  therefore  occupies  the  most 
dependent  position  when  the  woman  is  standing  upright.  The 
foetus,  lying  in  its  usual  attitude,  with  the  limbs  flexed,  is  most 
readily  accommodated  to  the  shape  of  the  uterus  when  its  antero- 
posterior diameter  nearly  corres^Donds  with  the  transverse,  or 
greatest,  diameter  of  the  uterine  cavity.  Its  back  is  most  frequently 
directed  forward,  and  not  backward,  partly  from  the  effect  of  the 
accommodation  of  the  shape  of  the  uterus  to  the  position  of  the 
maternal  spine,  which  has  been  already  mentioned  (see  p.  242), 
and  partly  from  the  effect  of  the  higher  specific  gravity  of  the 
spinal  column  of  the  foetus  when  the  woman  is  standing  upright. 
Hence  it  follows  that  the  back  of  the  child  is  generally  directed  to 
the  left  side,  and  somewhat  forward. 

Movements  of  the  Head  and  of  the  Trunk  of  the  Fcetus. 

It  has  already  been  explained  that  the  curved  axis  of  the  pelvis 
(Fig.  22,  p.  21)  is  a  line  drawn  to  represent,  as  nearly  as  possible, 


The   Mechanism  of   Labour. 


245 


the  path  described  by  the  centre  of  the  foetal  head  in  passing 
through  the  genital  canal.  While  the  centre  of  the  head,  and  in 
its  turn  the  trunk  of  the  fcetus,  is  passing  along  the  curve,  the 
head  and  the  body  make  certain  rotations  on  various  axes,  which 
it  is  important  to  study,  in  order  to  understand  the  mechanism  of 
labour,  and  its  modifications  under  various  circumstances.  The 
mechanism  will  first  be  described  for  the  case  in  which  the  head 


Fig.  153. — Diagram  showing  that  with  the  head  completely  flexed  the  maxi- 
mum vertico  mental  diameter  is  nearly  coincident  with  the  axis  of  the 
plane  of  the  pelvis  in  which  the  centre  of  the  head  is  lying.  (After 
Kaltenbach  Zeitsch  f.  Geb.  u.  Gyn.,  Bk.  XXI.) 


lies  in  the  left  occipito-anterior,  or  first,  position  (L.  0.  A.).     The 
most  important  of  these  movements  are  enumerated  as  follows  : — 

/Flexion. 

Internal  Eotation. 
DESCENTi  Extension. 

Restitution. 
^External  Rotation. 


Flexion. — While  the  meriibranes  are  still  unruptured,  and 
before  any  expulsive  force  has  begun  to  act  upon  the  foetus,  the 
head    lies   over    the  os   uteri    in  a  variable  position,   occasionally 


246 


The   Practice  of   Midwifery. 


partly  extended,  but,  as  a  study  of  frozen  sections  has  shown,  as  a 
rule  completely  flexed  with  the  chin  resting  on  the  sternum. 

If  the  liquor  amnii  is  abundant,  especially  in  a  multipara,  and  the 
head  is  not  engaged  in  the  pelvic  brim,  the  position  may  be  inter- 
mediate between  flexion  and  extension.  The  two  fontanelles  are 
then  nearly  on  the  same  level,  the  anterior  being  perhaps  somewhat 


OCCIPUT 


SINCIPUT 


Fig.  154. — Line  of  section  and  shape  of  suboccipito-bregmaticandof  occipito- 
frontal planes.  (From  lead  tape  tracings  by  Edgar,  Practice  of  Obstetrics, 
1904,  p.  467.) 


the  lowest,  owing  to  the  shape  of  the  head.  Both  fontanelles 
can  be  reached  with  about  the  same  readiness,  and  the  sagittal 
suture  between  them  crosses  the  centre  of  the  presenting  part. 
When,  however,  the  head  is  already  engaged  in  the  pelvic  brim,  as 
in  most  primiparse,  or  is  so  large  as  to  fit  tightly  into  the  lower 
segment  of  the  uterus,  the  liquor  amnii  in  that  part  being 
comparatively  scanty,  the  head  is  already  considerably  flexed 
before  the  rupture  of  the  membranes,  in  order  to  adapt  it  to  the 
containing  cavity.     As  soon  as  the  membranes  are  ruptured,  and 


The  Mechanism  of   Labour. 


247 


the  head  begms  to  meet  with  resistance,  either  from  the  cervix 
uteri,  or  other  part  of  the  genital  canal,  a  movement  of  flexion  of 
the  chin  upon  the  sternum  begins,  if  flexion  is  not  already  complete, 
associated  with  the  onward  movement  of  the  centre  of  the  head 
through  the  pelvic  brim.  By  this  movement,  which  is  really  a 
movement  of  accommodation,  a  mechanical  advantage  is  gained,  for, 
when  flexion  is  complete,  the  greatest  diameter  of  the  head  which 
has  to  pass  any  plane  of  the  pelvis  is  no  longer  the  longitudinal  or 
occipito-frontal  {of,  Fig.  89 ,  p.  128),  but  either  the  suboccipito- 
bregmatic  {sh,  Fig.  89,  p.  128),  or  one  nearly  approximating  to  it. 
The  length  of  the  occipito-frontal  diameter  being  about  4*6  inches 
(11*25  cm.),  with  a  circumference  of  13|  inches, 
and  that  of  the  suboccipito-bregmatic  only 
3'8  inches  (9*5  cm.),  with  a  circumference  of 
]  2f  inches,  there  is  thus  a  gain  of  about  three- 
quarters  of  an  inch  in  the  diameter,  or  of  one 
inch  in  the  circumference,  even  without  any 
moulding  of  the  head  (Fig.  154).  Also  the 
maximum  diameter  of  the  whole  head  {mx, 
Fig.  89),  instead  of  lying  at  all  across  the 
pelvis,  becomes,  when  flexion  is  comj)lete, 
nearly  coincident  with  the  axis  of  the  plane  in 
which  the  centre  of  the  head  is  lying  (Fig.  153). 
Cause  of  Flexion. — The  cause  of  flexion, 
when  it  does  occur,  is  twofold.  The  first 
cause  depends  upon  the  position  of  the  occipital 
condyles  nearer  to  the  occiput  than  to  the 
forehead,  the  second  upon  the  irregular 
shape  of  the  head.  The  first  cause  is  the 
simplest,  and  in  general  the  most  important, 
is   illustrated   by   Fig.    155.     Suppose   a   c   to 


Fig. 


155. — Diagram  of 
head  lever. 


Its  mode  of  action 
be  a  line  drawn 
parallel  to  the  axis  of  the  uterus  and  passing  through  the  occipital 
condyles.  This  will  be  the  direction  of  the  propulsive  force,  so 
far  as  this  depends  on  the  direct  uterine  pressure  on  the  fcetus  (see 
p.  232).  The  head,  in  entering  any  part  of  the  genital  canal,  will 
be  resisted  most  at  the  two  extremities  of  its  longest  or  antero- 
posterior diameter,  0  f  (Fig.  155),  and  the  resistances  at  0  and  f  may 
be  considered  equal.  The  head  may  then  be  regarded  as  a  lever, 
balanced  about  the  point  c,  where  the  line  of  propulsive  force  cuts 
0  F,  by  the  resistances  at  0  and  f.  Since  the  anterior  arm  f  c  of 
the  lever  is  longer  than  the  posterior  arm  o  c,  the  resistance  to  the 
forehead  will  have  the  mechanical  advantage,  and  the  forehead 
will  be  retarded  more  than  the  occiput.     When  labour  is  difficult 


248  The  Practice  of   Midwifery. 

and  prolonged,  so  that  most  of  the  hquor  amnii  drains  away,  and 
the  du'ect  uterine  pressure  is  the  chief  force  at  work,  the  move- 
ment of  flexion  so  produced  will  generally  go  on  until  it  is  stopped 
by  the  chin  being  pressed  firmly  against  the  sternum,  or  the  arm 
of  the  foetus,  which  is  often  forced  down  under  the  chin  by  the 
expulsive  force  (see  Fig.  131,  p.  220).  In  easy  rapid  labour,  when 
the  general  intra-uterine  pressure  is  the  chief  force  in  action, 
flexion  remains  more  moderate,  not  perhaps  exceeding  that  which 
exists  in  utero.  In  general,  advance  and  flexion  take  place  together, 
but  it  is  possible  for  flexion  to  occur  before  advance,  if  the  head  is 
about  to  enter  a  strait  of  the  pelvis  which  is  too  small  to  receive  it 
while  unflexed.      For,  during  a  pain,  the  occiput  may  be  pushed 


V 


bIM    / 
!  ')<  c 

G\/\ 

Fig.  156. — Diagram  to  illustrate  the  mode  in  which  flexion  is  produced  by 
the  pressure  of  the  girdle  of  contact  on  the  head. 

slightly  downwards,  and,  during  the  interval,  the  head  as  a  whole 
pushed  as  much  backwards  by  the  resistance  of  the  elastic  soft 
parts,  and  the  forehead  so  elevated.  In  this  way  the  occiput  may 
be  slightly  dejDressed,  and  the  forehead  slightly  elevated  alternately 
until  sufficient  flexion  has  been  produced  to  allow  the  head  to 
advance  as  a  whole  into  the  narrow  part,  whether  constituted  by 
the  bony  pelvis,  the  cervix,  or  soft  parts  elsewhere. 

The  second  cause  of  flexion  comes  into  play  even  if  there  is  no 
force  transmitted  through  the  condyles,  the  only  propelling  force 
being  the  general  fluid  pressure,  transmitted  to  the  foetus  through 
the  liquor  amnii. -^  It  arises  from  the  relation  between  the  shaj^e 
of  the  head  and  the  pressure  exercised  upon  it  at  the  girdle  of 

1  See  Lahs.,  "  Die  Theorie  der  Geburt,"  Bonn,  1887. 


The  Mechanism  of   Labour. 


249 


Fig.  157. — Diagram  to  illustrate 
the  increase  of  flexion  by  pres- 
sure after  the  head  has  entered 
the  genital  canal. 


contact  either  with  the  os  uteri,  or  the  yet  imperfectly  expanded 

soft  parts  elsewhere.     The  head,  looked  at  from  the  side,  is  seen  to 

form  an  unequal  wedge,  the  slope  at 

the  occipital  end  being  steeper  than 

at  the  frontal  (see  Fig.  89,  p.  128, 

and  Fig.  156).      Fig.  156  represents 

the   head,   the   still  imperfectly  ex- 
panded OS  uteri  forming  the  girdle  of 

contact.        The     resultant     of     the 

general  fluid  pressure  acts  perpen- 
dicularly through  the  centre  of  the 

OS,  in  the  line  f  g.      The  pressures 

at  the  girdle  of  contact  (disregarding 

friction)  act  perpendicularly  to  the 

surface,  that   is,  at  the  ends  of  the 

longest  diameter  engaged  (a  b),  they 

act  along  the  lines  a  h,  b  h.     Their 

resultant  must  act  through  the  point  h  where  these  lines  meet,  and 

it  must  act  perpendicularly  to  the  plane  of  the  os,  if  the  head  as  a 

whole  is  not  being   pushed  toward  the  forehead,  or  toward  the 

occiput,  that  is  to  say,  it  acts  in  the 
line  D  E  parallel  to  f  g.  We  have 
then  two  equal  forces  acting  in 
opposite  directions,  but  not  in  the 
same  straight  line.  This  forms 
what  in  mechanics  is  called  a 
couple,  and  it  will  cause  the  occiput 
to  descend  and  the  forehead  to 
rise  until  the  tangents  at  a  and  b 
are  equally  inclined  to  f  g,  in  which 
case  the  point  h  and  also  the  point 
c  will  lie  upon  f  g.  If  friction  is 
taken  into  account,  it  will  some- 
what limit  the  effect  produced,  so 
that  the  angles  which  the  tangents 
at  A  and  b  make  with  the  plane  of 
the  OS  will  not  become  perfectly 
equal,  but  it  will  not  alter  its 
general     character.        It    will    be 

observed  that  flexion,  produced  by  this  cause,  need  not  go  so  far  as 

to  bring  the  chin  into  contact  with  the  sternum. 

A  second  effect  of  the  pressure  of  the  girdle  of  contact  is  produced 

during  the  intervals  of  the  pains,  when  a  partial  flexion  has  already 


Fig.  158. — Outline  of  the  internal 
surface  of  the  left  half  of  the 
pelvis.  The  two  curved  lines 
mark  the  path  of  the  occiput  in 
the  first,  and  in  the  occipito- 
anterior termination  of  the 
fourth  position. 


250 


The   Practice  of   Midwifery. 


occurred.  Fig.  157  represents  a  head  in  such  a  position  engaged 
in  a  cyhndrical  elastic  canal.  The  pressures  at  a  and  b  during 
the  intervals  of  propelling  force  will  act  perpendicularly  to   the 


1^4 


-t/.i 


V^.i 


Fig.  159. — Diagram  of  mechanism  of  labour  illustrating  the  movements  of 
head  and  shoulders  in  their  passage  through  the  pelvis.  Outline  =  pelvis 
looked  at  from  above  and  behind  ;  arrow  =  occipito  frontal  diameter  of 
head  ;  arrov^r  head  =  occiput ;  —\  =  bis-acromial  diameter  of  shoulders  ; 
short  limb  =  right  shoulder  ;  i.  v.  -i,  L.O.P.  head  entering  pelvis,  occ.  fr. 
diam.  in  left  oblique  diam.,  bis-acrom.  diam.  of  shoulders  in  rt.  obi.  diam. 
of  pelvis  ;  ii.,  internal  rotation  forwards  of  occiput  through  J-  of  circle  ; 
iii.,  further  internal  rotation  of  occiput  through  ^  of  circle  and  conversion 
into  V.  i.  L.O.A.  ;  iv.,  v.  i.  L.O.A.  occ.  fr.  diam.  in  rt.  obi.  bis-acrom.  diam.  of 
shoulders  in  left  obi.  of  pelvis  ;  v.,  internal  rotation  of  occiput  through 
I  of  circle  to  front ;  vi.,  birth  of  head  by  movement  of  extension,  occiput 
leading,  showing  twist  of  head  on  shoulders  ;  vii.,  restitution,  occiput 
rotating  back  towards  original  position  to  undo  twist ;  viii.,  external 
rotation  of  occiput  with  internal  rotation  of  right  shoulder  to  the  front ; 
ix.,  birth  of  shoulders,  right  shoulder  leading. 


surface  in  the  direction  of  the  arrows.  They  will  thus,  as  shown 
in  the  figure,  form  a  pair  of  equal  forces,  or  "  couple,"  tending  to 
rotate  the  head  on  a  transverse  axis,  so  as  to  increase  its  flexion. 
This  kind  of  pressure  will  be  exercised  even  by  the  lower  segment 
of  the  uterus  and  before  the  onset  of  labour,  but  especially  after  the 


The  Mechanism  of   Labour.  251 

rupture  of  the  membranes.  Together  with  the  general  tendency  of 
flexor  to  preponderate  over  extensor  muscles,  it  is  the  cause  of  the 
flexion  existing  in  utero. 

The  effect  of  flexion  is  that,  instead  of  the  examining  finger 
touching  a  point  near  the  middle  of  the  sagittal  suture,  the 
posterior  fontanelle  becomes  progressively  more  within  reach,  and 
the  anterior  fontanelle  relatively  higher.  When  flexion  is  complete 
the  posterior  fontanelle  may  be  nearly  at  the  centre  of  the  present- 
ing part  and  of  the  caput  succedaneum,  while  the  anterior  fontanelle 
may  be  out  of  reach,  especially  when  the  head  is  much  elongated 
by  moulding. 

Internal  Rotation.— By  the  movement  of  internal  rotation  the 
long  diameter  of  the  head  changes  from  a  position  not  far  from 
the  transverse  diameter  of  the  pelvis  into  the  antero-posterior  or 
nearly  so.  In  this  rotatory  movement,  therefore,  the  head  describes 
rather  more  than  one- eighth  of  a  circle.  It  emerges  beneath  the 
pubes  with  the  sagittal  suture  directed  almost,  but  not  quite,  in  an 
antero-posterior  direction  (see  Fig.  137,  p.  228,  and  Fig.  161). 
This  is  called  a  short  internal  rotation  in  contradistinction  to  the 
long  internal  rotation  which  occurs  in  occipito-posterior  positions. 

Causes  of  Internal  Flotation. — Internal  rotation  is  due,  in  the 
first  place,  to  a  screw-like  mechanism,  the  longest  diameter  of  the 
head  accommodating  itself  to  the  longest  diameter  of  the  pelvis, 
which  progressively  changes  from  a  transverse  to  an  antero-posterior 
direction.  In  some  cases  of  contracted  pelvis  where  the  head  fits 
the  pelvis  tightly  the  anterior  inclined  plane  of  the  ischium  may 
help  in  directing  the  occiput  forwards,  and  the  posterior  inclined 
plane  of  the  ischium,  coming  into  play  at  a  higher  level,  may  help 
in  directing  the  forehead  backwards.  It  is  ]3robable,  however,  that 
in  most  instances  the  rotation  of  the  head  is  brought  about  by  some 
other  agency  than  the  inclined  planes  of  the  pelvis.  As  soon  as  the 
head  has  descended  into  the  cavity  of  the  pelvis  the  action  of  the 
sloping  posterior  and  lateral  walls  of  the  pelvic  floor  must  be  taken 
into  account.  These  together  form  a  sloping  gutter  which  tends  to 
direct  any  body  coming  into  contact  with  it  downwards  and  forwards 
into  the  free  space  under  the  pubes  formed  by  the  vaginal  outlet. 

The  forecomiug  part  of  the  head,  in  the  case  of  the  vertex  the 
occiput,  is  directed  forwards  by  these  sloping  walls,  and  rotates 
towards  the  free  space  under  the  pubes,  in  the  direction  of  least 
resistance.  This  movement  takes  place  quite  independently  of  the 
screw-like  form  of  the  l)ony  pelvic  walls,  and  occurs  both  in 
occipito-aiiterior  and  occipito-posterior  presentations.     The  action 


252 


The  Practice  of   Midwifery. 


of  the  sloping  gutter  of  the  pelvic  floor  is  aided  by  the  shape  of  the 
opening  in  the  levator  ani  muscle  through  which  the  head  has  to 
pass,  which  has  the  form  of  an  ellipse  with  its  long  diameter 
directed  antero -posteriorly. 

Some  writers,  in  view  of  the  difficulty  of  explaining  the  forward 
rotation  of  the  forehead  in  cases  of  unreduced  occipito-posterior 


Fig.  T 60.— Section  showing  the  genital  tract  towards  the  close  of  the  second 
stage  of  labour.  The  fundus  is  at  the  level  of  the  first  lumbar  vertebra. 
The  retraction  ring  is  well  marked  ;  the  anterior  vaginal  wall  is  its  usual 
length,  2  inches,  while  the  posterior  vaginal  is  greatly  stretched  and 
measures  7  inches  ;  the  placenta  is  not  separated,  and  the  anus  and 
perineum  are  stretched.     (Vide,  Fig.  142,  p.  236,  Barbour.) 

presentations,  maintain  that  the  rotation  forwards  of  the  forecoming 
part  of  the  head  is  in  reality  due  to  a  rotation  of  the  body  of  the 
child.  Owing  to  the  projection  forwards  of  the  lumbar  spine  of  the 
mother,  there  is  a  tendency  for  the  spine  of  the  child  to  turn  away 
from  the  spine  of  the  mother  (see  p.  244),  and  as  during  a  con- 
traction the  uterus  becomes  flattened  antero-posteriorly,  if  the  back 
of  the  fcetus  is  placed  obliquely,  the  uterine  contractions  will  tend 
to  rotate  it  to  the  front.     During  a  uterine  contraction   the  trunk 


The  Mechanism   of   Labour.  253 

and  the  head  of  the  foetus  may  be  considered  as  forming  one  body, 
and  therefore  any  rotation  forwards  of  the  back  will  be  accompanied 
by  a  similar  rotation  of  the  occiput.  If  this  is  the  explanation  of 
the  rotation  of  the  forecoming  part  forwards,  then  we  must  hold 
with  Schrceder  that  the  rotation  of  the  shoulders  does  not  take 
place  to  so  complete  a  degree  as  that  of  the  head,  and  that  the 
com]3lete  rotation  of  the  latter,  although  initiated  in  this  manner, 
is  completed  by  other  accessory  causes. 

Sellheim  has  lately  put  forward  the  view  that  the  rotations  of  the 
foetus  in  its  passage  through  the  birth  canal  can  be  explained  on 
purely  mechanical  grounds.  He  maintains  that  if  a  body  capable 
of  being  bent  in  different  directions  with  varying  degrees  of  facility 
is  pushed  through  a  curved  cylindrical  canal,  it  will  pass  with  the 
greatest  ease  when  its  most  bendable  flexures  correspond  to  the 
most  marked  curves  of  the  cylinder. 

In  the  case  of  the  foetus,  in  the  normal  attitude  of  flexion  it 
maintains  in  utero,  the  movement  which  can  take  place  most 
readily  is  extension  of  the  head  on  the  trunk.  Hence  during  its 
passage  through  the  pelvic  canal  its  body,  following  this  law,  rotates 
in  such  a  manner  as  to  bring  the  back  of  the  neck  into  contact  with 
the  under-aspect  of  the  pubes,  and  also  to  permit  of  extension  of  the 
head  taking  place  with  the  greatest  facility. 

In  the  case  of  a  face  presentation  the  movement  of  flexion  of  the 
head  is  the  one  which  can  occur  most  readily,  and  therefore  rotation 
takes  place  in  such  a  manner  as  to  bring  the  chin  under  the  pubes, 
and  so  to  permit  of  flexion  of  the  head  on  the  trunk. 

Extension. — Flexion  is  maintained  until  the  head  meets  the 
resistance  of  the  inclined  plane  looking  forward  formed  by  the 
soft  parts  which  constitute  the  pelvic  floor  (see  Fig.  132,  p.  221). 
The  reverse  movement  of  extension  then  commences  (see  Fig.  161). 
The  chin  becomes  separated  from  the  sternum  ;  the  head  moves 
almost  as  if  it  were  rotating  about  a  transverse  axis  passing  through 
a  point  somewhere  in  the  symphysis  pubis  (except  that  the  movement 
of  internal  rotation  around  a  quite  different  axis  is  generally  also 
still  proceeding).  The  forehead  moves  faster  than  the  occiput, 
having  to  go  along  the  outside  of  the  curve  while  the  occiput  moves 
along  the  inside;  but  no  point  on  the  head  is  arrested,  and  the 
posterior  fontanelle  is  nearly  in  the  centre  of  the  part  which  first 
protrudes  through  a  vulva  not  previously  lacerated  (see  Figs.  136, 
p.  227;  and  162).  Eventually,  as  the  head  escapes  through  the 
vulva,  the  occiput  becomes  turned  somewhat  upward  in  front  of  the 
pubes  (see  Figs.  162,  163,  164  (4)).     Meanwhile  the  perineum  and 


254 


The   Practice  of   Midwifery. 


the  soft  parts  behind  the  anus  become  greatly  stretched,  the  anus 
itself  expanded,  and  the  anterior  margin  of  the  perineum  drawn 
forward  (see  Fig.  22,  p.  21,  and  Figs.  161,  162,.  163).  The  ring 
formed  by  the  vulval  outlet  is  at  its  greatest  tension  when  the 
forehead  is  just  passing  the  fourchette,  and  the  girdle  of  contact 
formed  by  it  then  encircles  the  head  nearly  in  the  plane  of  the 
suboccipito-frontal  diameter  {sy,  Fig.  89,  p.  128).  If  the  promi- 
nence of  the  forehead  has  once  passed  without  rupture,  the  perineum 
slips  quickly  over  the  face,  and,  as  soon  as  the  chin  is  released,  the 
extension  of  the  head  is  diminished. 

Cause  of  Extension. — Extension  is  caused  by  the  resistance  of  the 

inclined  plane  of  elastic  soft 
parts  looking  forward,  which 
forms  the  pelvic  floor,  acting  in 
conjunction  with  the  propelling 
force  of  the  uterus,  the  direction 
of  which  is  not  far  removed  from 
the  axis  of  the  brim,  except  in 
those  cases  in  which  so  much 
liquor  amnii  is  retained  that  the 
main  force  at  work  is  still  the 
general  intra-uterine  pressure. 
This  inclined  plane  is  well 
shown  in  the  frozen  sections 
(Figs.  131,  p.  220,  and  132, 
p.  221).  Although  the  membranes 
are  there  unruptured,  the  second 
stage  is  shown  so  far  advanced 
that  the  head  is  just  beginning  to 
press  on  the  pelvic  floor.  Further 
advance  in  the  direction  of  the  axis  of  the  brim  is  prevented  by  the 
resistance  of  the  sloping  floor,  and  the  forecoming  part  of  the  head 
which  meets  the  resistance  is  directed  forward.  The  resistance  of 
the  pubes  to  the  aftercoming  part  of  the  head  and  the  attachment 
of  the  head  to  the  neck  prevent  the  head  moving  forwards  as  a 
whole,  and  the  occiput,  its  forecoming  part,  can,  therefore,  only  go 
forward  by  a  movement  of  extension.  If  the  front  of  the  child  is 
directed  forwards,  as  in  face  presentations,  or  unreduced  occipito- 
posterior  positions  of  the  vertex,  precisely  the  same  mechanism 
produces  flexion,  as  will  be  seen  hereafter,  and  if  the  head  escapes 
with  its  long  diameter  directed  laterally,  as  happens  in  rare  cases 
only,  it  produces  lateral  flexion  of  the  head  toward  the  anterior 
shoulder. 


Fig.  161. — Commencement  of  extension, 
showing  position  of  fontanelles. 


The  Mechanism  of   Labour. 


255 


Restitution. — In  most  cases  the  shoulders  only  partially  follow 
the  internal  rotation  of  the  head.  The  head  then,  immediately  on 
its  escaj)e  from  the  vulva,  turns  back  towards  the  direction  it 
originally  occupied,  so  as  to  accommodate  itself  to  the  position  of  the 
shoulders.  The  term  restitution  is  usually  applied  to  this  move- 
ment, which  is  followed  as  the  shoulders  rotate  on  their  passage 
through  the  pelvis  by  the  movement  of  external  rotation  of  the 
head  (Fig.  159,  vii.).  " 

External  Rotation. — After  it  has  emerged  from  beneath  the 
pubic  arch  and  escaped  from  the  perineum,  the  head,  after  under- 


FiG.  162. — First  stage  of  extension. 


Fig.  163. — Second  stage  of  extension. 


going  the  movement  of  restitution,  rotates  back  again  still  further 
toward  the  direction  which  it  occupied  at  first,  the  face  becoming 
turned  toward  the  right  thigh  of  the  mother.  This  is  due  to  the 
effect  of  the  screw-like  mechanism  of  the  pelvis  and  canal  of  soft 
parts  on  the  shoulders  and  body  of  the  child.  The  long  diameter 
of  the  shoulders  is  from  side  to  side,  and,  like  the  long  diameter  of 
the  head,  it  accommodates  itself  to  the  longest  diameter  of  the 
pelvis  as  it  descends,  turning  from  the  oblique  into  the  antero- 
posterior. Occupying  at  first  the  left  oblique  diameter  of  the  pelvis, 
the  right  shoulder  anterior,  it  turns  into  the  antero-posterior  at 
the  outlet,  the  right  shoulder  escaping  under  the  pubic  arch,  the 
left  shoulder  sliding  over  the  perineum.  The  elliptic  shape  of 
the  opening  of  the  levator  ani  supplements  the  efl'ect  of  the  pelvic 


256  The   Practice  of   Midwifery. 

pressure  on  the  shoulders  as  it  does  that  upon  the  head.  The 
rotation  of  the  shoulders  is  thus  opposite  in  direction  to  the 
previous  rotation  of  the  head.  Occasionally  it  happens  that 
the  head  has  rotated  completely  into  the  antero-posterior,  and  the 
shoulders,  following  the  rotation  of  the  head,  completely  into  the 
transverse  diameter  of  the  pelvis.  In  this  case  the  rotation  of  the 
shoulders  is  as  likely  to  go  on  in  the  same  direction  as  to  be 
reversed.  If  it  does  so,  the  left  shoulder  comes  out  under  the  pubic 
arch,  and  the  face  turns  toward  the  mother's  left  thigh. 

Relation  of  Movements  to  each  other. — It  will  be  observed 
that  the  first  and  third  of  these  movements,  flexion  and  extension, 
are  the  reverse  of  each  other,  and  so  also  are  the  second  and  fifth, 
internal  rotation  and  external  rotation.  The  movements  do  not, 
however,  take  place  separately  and  successively,  but  generally  two 
of  them  are  going  on  together,  in  conjunction  with  the  descent  of 
the  centre  of  the  head.  Thus  with  the  descent  of  the  head  through 
the  main  part  of  the  bony  pelvis  are  combined  flexion  and  internal 
rotation.  As  soon  as  the  head  meets  the  inclined  plane  of  the 
pelvic  floor,  or  rather  as  soon  as  the  effect  of  the  resistance  of  this 
inclined  plane  preponderates  over  the  forces  tending  to  produce 
flexion,  flexion  ceases  and  extension  begins.  Descent,  internal 
rotation  and  extension  then  go  on  together  until  the  head  escaj)es 
from  the  perineum.  At  this  point  external  rotation  is  substituted 
for  its  opposite,  internal  rotation.  When,  by  the  elasticity  of  the 
soft  parts,  the  head  is  pushed  back  in  the  interval  of  pains,  not 
only  descent,  but  the  other  movements,  are  generally  reversed  for 
the  time,  more  especially  internal  rotation.  Thus  the  head  recedes, 
as  well  as  advances,  by  a  screw-like  movement.  The  successive 
stages,  for  the  first  position,  are  shown  in  Fig.  164,  p.  257. 

In  the  second,  or  right  occipito -anterior  position  of  the  vertex, 
the  mechanism  is  precisely  the  same  as  in  the  first  or  left  occipito- 
anterior, except  that  left  is  substituted  for  right,  and  the  directions 
of  internal  and  external  rotation  are  reversed.  In  the  frozen  section. 
Fig.  ]31,  p.  220,  the  foetus  is  seen  to  be  in  the  second  position.  The 
head  is  beginning  to  press  upon  the  inclined  plane  of  the  pelvic 
floor,  and  the  force  which  transforms  flexion  into  extension  is  thus 
beginning  to  act.     Internal  rotation  is  not  yet  complete. 

Mechanism  in  Occipito-posterior  Positions. —  SujDpose  the 
head  to  be  in  the  third  or  right  occiijito-posterior  i^osition,  flexion 
takes  place  as  in  occipito-anterior  positions,  and  for  the  same  reason. 
With  internal  rotation  the  mechanism  is  different.     The  head  being 


The   Mechanism  of   Labour. 


■SI 


well  flexed,  the  occiput  comes  down  much  in  advance  of  the  forehead, 
and  is  the  first  to  meet  the  resistance  of  the  inclined  plane  of  the 
pelvic  floor,  which  pushes  it  forward.  At  the  same  time  there  is 
free  space  under  the  puhic  arch,  and  the  occiput,  therefore,  usually 
turns  away  from  the  resisting  plane  until  it  is  directed  nearly 
forwards,  and  escapes  under  the  pubic  arch.  As  soon  as  the  occiput 
has  begun  to  be  directed  anteriorly,  the  elliptic  opening  of  the  levator 
ani  aids  in  completing  the  rotation,  as  in  primary  occipito-anterior 


Fig.  164. — Successive  stages  of  first,  or  left  occipito-anterior,  position  of  vertex. 

positions.  The  position  is  thus  converted  into  the  second  or  right 
occipito-anterior,  and  the  movements  of  extension,  restitution  and 
external  rotation  take  place  just  as  if  the  head  had  been  originally 
in  that  position.  The  internal  rotation  in  occipito-posterior 
positions  therefore  takes  place  through  nearly  three-eighths  of 
a  circle,  instead  of  only  a  little  more  than  one-eighth  (see  Fig.  158, 
p.  249),  and  is  called  a  long  rotation. 

Sometimes  this  rotation  begins  before  the  true  floor  of  the  pelvis 
is  reached,  and  the  inclined  plane  which  causes  it  is  then  that 
formed  by  the  recto-vaginal  septum.  Whether  the  rotation  occurs 
early  or  late,  the  resistance  which  causes  it  is  that  of  the  soft  parts, 

M.  17 


258 


The  Practice   of    Midwifery. 


Fig.  165. — Escape  of  head  by  flexion 
in  unreduced  occipito-posterior 
position,  first  stage. 


Fig.  166. — Escape  of  head  by  flexion 
in  unreduced  occipito-posterior 
position,  second  stage. 


a^.3 


Fig.  167. — Diagram  of  mechanism  of  labour  in  unreduced  occipito-posterior. 
(For  general  explanation,  see  Fig.  1.59.)  i.,  R.O.P.,  V.  3.,  occ.  fr.  diam.  rt. 
obliq.,  bis-acrom.  diam.  left  obliq.  ;  ii.,  rotation  of  forehead  though  J  circle 
forwards  ;  iii.,  birth  of  head  by  movement  of  flexion,  forehead  leading  ; 
iv.,  restitution,  rotation  of  forehead  towards  original  direction  ;  v.,  external 
rotation  with  rotation  of  anterior  left  shoulder  forwards  ;  vi.,  birth  of 
shoulders,  left  shoulder  leading. 


The  Mechanism  of   Labour. 


259 


and  not  of  the  planes  of  the  ischia,  or  any  part  of  the  bony  pelvis. 
The  screw-like  mechanism  of  the  bony  pelvis  would  rather  deter- 
mine a  rotation  of  the  occiput  backwards,  since  the  occiput  is 
originally  behind  the  spine  of  the  ischium.  This  is  further  proved 
by  experiment,  for  it  has  been  shown  that  if,  in  the  corpse  of  a 
woman  who  has  died  during  or  just  after  delivery,  a  foetus  be 
placed  in  an  occipito-posterior  position,  after  the  uterus  has  been 
opened,  and  pushed  through  from  above,  the  rotation  takes  place  in 


Fig.  168. — Successive  stages  of  fourth,  or  left  occipito-posterior,  position  of 
the  vertex,  when  unreduced. 

the  natural  way  if  the  soft  parts  are  intact,  but  not  if  they  are 
lacerated,  or  greatly  over-distended  in  repetition  of  the  experiment. 
In  the  fourth  or  left  occipito-posterior  position  of  the  vertex,  the 
mechanism  is  precisely  the  same.  The  occiput  usually  first  rotates 
to  the  left  and  then  forwards.  The  position  is  thus  converted  into 
the  first  or  left  occipito-anterior,  and  extension  and  external  rotation 
take  place  as  if  the  head  had  been  in  that  position  originally. 


Mechanism  in  Unreduced  Occipito-posterior  Positions. — In 
some  cases  the  rotation  forwards  of  the  occiput  fails,  but  probably 
in  not  more  than  about  one-tenth  of  the  whole.     In  these  cases,  as 

17—2 


26o 


The  Practice  of   Midwifery. 


the  flexion  of  tlie  head  is  generally  deficient,  the  forehead  forms  the 
forecoming  part,  and  coming  first  into  contact  with  the  sloping 
gutter  of  the  pelvic  floor,  is  directed  by  the  usual  mechanism  to  the 
front  by  rotating  through  one  eighth  of  a  circle,  the  occiput  conse- 
quently rotating  back  into  the  hollow  of  the  sacrum.  In  this 
position  the  head  reaches  the  pelvic  floor.     The  resistance  of  the 

inclined  plane,  pushing  forward 
the  forecoming  part  of  the  head, 
then  causes  a  movement  not  of 
extension,  but  of  flexion  (see 
Figs.  165,  166,  168),  and  by  this 
movement  of  flexion  the  head 
escapes,  the  forehead  passing 
beneath  the  pubic  arch,  while  the 
occiput  passes  over  the  perineum. 
The  occiput,  in  this  case,  has  to 
go  along  the  outside  of  the  curve, 
and  therefore  moves  faster  than 
the  forehead.  The  anterior  fon- 
tanelle  is  then  often  nearly  in  the 
centre  of  the  presenting  part,  as 
the  head  is  reaching  the  vulval 
outlet.  This  mode  of  escape  of  the 
head  involves  a  serious  mechanical 
disadvantage.  (Compare  Figs.  165, 
166,  with  Figs.  161,  162,  163.) 
Instead  of  the  suboccipito-breg- 
matic,  measuring  only  3|  inches 
(9*5  cm.),  and  finally  the  sub- 
occipito-frontal  diameter,  either 
the  occipito-frontal,  measuring  4| 
inches  (11-25  cm.),  or  a  diameter 
not  far  removed  from  it,  is  opposed 
to  the  antero- posterior  diameter 
of  the  outlet  of  the  genital  canal.  With  a  normal  size  of  foetus 
and  of  maternal  passages,  the  head  cannot  generally  so  pass,  except 
by  rupture  of  the  perineum,  until  it  has  been  so  moulded  by 
pressure  as  greatly  to  diminish  the  occipito-frontal  diameter. 
Even  after  such  moulding,  difficulty  often  occurs,  the  risk  of 
rupture  of  perineum  is  always  increased,  and  artificial  delivery  is  not 
infrequently  called  for. 

The  chief  cause  of  failure  of  the  usual  rotation  of  the  occiput 
forward  is  deficient  flexion  of  the  head,  whether  this  be  due  to 


SINCIPUT 


Fig.  169. — Line  of  section  and  shape 
of  suboccipito  frontal  diameter. 
(From  Edgar,  lead  tape  tracing, 
Practice  of  Obstetrics,  Fig.  549.) 


The   Mechanism  of   Labour. 


261 


contraction  of  the  conjugate  diameter  of  the  pelvis,  or  any  other 
reason.  For  the  reason  why  the  occiput  tarns  forward  is,  as 
already  mentioned,  that,  coming  in  advance,  it  is  the  first  part  to 
meet  the  inclined  plane  of  soft  parts.  If,  however,  the  occiput  and 
forehead  are  descending  on  the  same  level,  there  is  no  reason  why 
the  occiput  should  be  pushed  forward  any  more  than  the  fore- 
head. Even  if  the  flexion  is  merely  less  marked  than  usual, 
the  excess  of  the  pressure  forwards  on  the  occiput  over  that  on  the 
forehead  may  be  insufficient  to  overcome  the  resistance  of  friction. 
The  resistance  to  rotation  due  to  friction  will  of  course  be  greater  the 
more  tightly  the  head  is  fitted  in  the  pelvis.  Hence  a  large  size 
of  the  foetal  head  in  proportion  to 
the  pelvis  may  be  one  of  the 
causes  which  contribute  towards 
the  occiput  remaining  posterior. 
Another  cause  may  be  descent  of 
the  head  low  in  the  pelvis  still 
covered  by  an  incompletely-dilated 
OS  uteri.  For  the  rim  of  the  os 
uteri,  by  retarding  the  occiput, 
which  should  escape  first,  tends  to 
prevent  complete  flexion. 

In  about  one-half  of  the  cases 
of  unreduced  occipito  -  posterior 
presentations  the  child  is  prema- 
ture or  undeveloped,  and  no  doubt 
in  such  conditions  the  small  size 
of  the  head  enables  it  to  pass 
through  the  pelvis  almost  in  the 
same  position  as  that  in  which  it 
entered  it.  In  dorso-posterior  positions  of  the  trunk  the  projection 
of  the  lumbar  spine  of  the  mother  may  play  a  part  in  producing 
some  extension  of  the  head  on  the  trunk  of  the  foetus,  and  in 
occipito-posterior  presentations  the  head  enters  the  pelvic  brim  less 
readily  as  a  rule  than  in  occipito-anterior  presentations,  and  thus 
some  degree  of  extension  may  be  set  up  (Fig.  171). 

Movements  of  restitution  and  external  rotation  take  place  in 
unreduced  occipito-posterior  positions,  as  well  as  in  other  cases. 
The  face  turns  generally  to  the  side  toward  which  it  originally 
looked;  to  the  left  in  the  third  position,  to  the  right  in  the  fourth 
position.  This  rotation  is  due,  as  before,  to  the  untwisting  of  the 
head  on  the  shoulders,  and  to  the  movement  of  the  shoulders  in 
descending  through  the  outlet  of  the  genital  canal. 


Fig.  170 

ing 


-Diagram  of  head  present- 
at  brim,  with  occiput 
posterior  showing  longest  trans- 
verse diameter,  the  bi-parietal 
occupying  a  diameter  of  the 
brim  less  than  the  longest 
oblique  diameter.  In  occipito- 
anterior presentations  the  bi- 
parietal  diameter  occupies  the 
oblique  diameter.  (Herman, 
Difficult  Labour,  Fig.  6.) 


262  The   Practice  of   Midwifery. 

The  successive  stages  of  an  unreduced  occipito-posterior  position 
are  shown  in  Fig.  168,  p.  259. 

Lateral  Obliquity  of  the  Foetal  Head. — In  the  older  works  on 
midwifery,  besides  the  five  movements  of  flexion,  internal  rotation, 
extension,  restitution,  and  external  rotation,  a  sixth  movement  or 
condition  called  obliquity  was  described.      By  this  was  meant  a 


Fia.  171. — Section  showing  partial  extension  of  spine  when  the  occiput  is 
behind.     (Modified  from  Varnier,  Pratique  des  Accouchements,  Fig.  172.) 

kind  of  lateral  or  bi-parietal  obliquity  of  the  head,  which,  for 
distinction,  is  called  the  Naegele-obliquity,  because  it  was  first 
described  by  Naegele.^  The  Naegele-obliquity  means  a  rotation  of 
the  head  on  its  antero -posterior  axis,  so  that  the  anterior  parietal 
bone  {i.e.,  in  the  first  position,  the  right  parietal  bone)  lies  most 
deeply  in  reference  to  the  plane  of  the  brim,   the  middle  of  the 

1  Two  other  obliquities  of  the  foetal  head  at  the  brim  have  sometimes  been  spoken 
of  :— Koederer's  obliquity,  by  which  is  meant  the  chin  flexion  ;  and  Solayres'  obliquity, 
by  which  is  meant  the  entrance  of  the  long  diameter  of  the  head  in  an  oblique  diameter 
of  the  pelvis. 


The   Mechanism  of   Labour. 


263 


sagittal  suture  is  nearer  to  the  promontory  of  the  sacrum  than  to 
the  top  of  the  symphysis  pubis,  and  the  anterior  parietal  tuber  is 
in  advance  of  the  posterior.  For  this  reason  it  is  often  called 
anterior  parietal  obliquity.  By  this  is  implied,  assuming  the  axis 
of  the  child  to  be  perpendicular  to  the  brim,  a  lateral  flexion  of  the 
child's  head  toward  its  j^osterior  shoulder,  the  left  shoulder  in  the 
first  and  fourth  positions,  the  right  shoulder  in  the  second  and 
third  (Fig.  174).  If  Naegele-obliquity  exists  before  the  os  is  fully 
dilated,  and  the  os  itself  is  centrally  situated  in  reference  to  the 
axis  of  the  brim,  the  sagittal 
suture  will  divide  the  os  into 
two  unequal  parts,  the  anterior 
being  the  largest.  In  Figs.  172, 
173,  is  shown  a  slight  Naegele- 
obliquity,  still  persisting  as  the 
head  is  approaching  the  outlet 
of  the  bony  pelvis  in  the  first 
and  third  positions  respectively. 
It  is  to  be  observed  that,  even 
without  any  Naegele-obliquity, 
the  '.^anterior  parietal  bone 
always,  when  the  head  is  at  the 
brim  or  in  the  cavity  of  the 
pelvis,  lies  most  deeply  in 
reference  to  the  horizon,  though 
not  in  reference  to  the  plane  of 
the  brim,  simply  in  consequence 
of  the  oblique  position  of  the 
long  diameter  of  the  head,  and 
the  inclination  of  the  brim 
itself  to  the  horizon. 

Two  among  the  reasons  given  by  Naegele  for  inferring  the  lateral 
or  bi-parietal  obliquity  of  the  head  were  the  following.  First  that 
the  examining  finger,  when  introduced,  touches  the  right  parietal 
bone  (in  the  first  position)  in  the  vicinity  of  the  tuber,  and  not  a 
point  in  the  sagittal  suture.  This,  however,  is  simply  the  result  of 
the  head  lying  in  the  oljlique  diameter  of  the  brim,  and  the  inclina- 
tion of  the  outlet  of  the  pelvis  to  the  inlet.  A  second  reason  was 
that  the  caput  succedaneum  formed  before  complete  dilatation  of 
the  OS  is  situated  upon  the  right  parietal  bone,  near  its  upper  edge, 
and  not  centrally  over  the  sagittal  suture.  This,  however,  may  be 
explained,  as  it  has  been  by  Matthews  Duncan,  without  assuming 
any  lateral  obliquity,  on  the  ground  that  the  caput  succedaneum 


Fia.  172. — Ou  1  I     I    I  'is,  showing  a 

slight  Naegele-obliquity  of  the  foetal 
head,  which  is  passing  through  the 
pelvic  cavity  in  the  first  position.  The 
asterisli  marks  the  presenting  point. 
(After  Tyler  Smith.) 


264 


The  Practice  of   Midwifery. 


will  be  thickest  where  the  head  is  least  supported.  The  thickest 
part  will  therefore  be,  not  necessarily  in  the  centre  of  the  os  uteri, 
but  rather  in  the  direction  of  the  axis  of  the  undilated  vagina,  while 
in  other  parts  within  the  circle  of  the  os  uteri,  where  partial  support 
is  received  from  the  posterior  vaginal  wall,  the  swelling  may  be  so 
inconsiderable  as  not  to  attract  notice.  These  two  points  therefore 
do  not  prove  any  Naegele-obliquity,  and  its  existence  is  only  to  be 
inferred  when  it  can  be  made  out  that  the  centre  of  the  sagittal 
suture  is  nearer  to  the  promontory  of  the  sacrum  than  to  the  top  of 


Fig.  173. — Outlet  of  the  pelvis,  showing  a 
slight  Naegele-obliquity  of  the  foetal 
head,  which  is  passing  through  the 
pelvic  cavity  in  the  third  position.  The 
asterisk  marks  the  presenting  point. 
(After  Tyler  Smith.) 


Fig.  174.- — Foetus  from  case  of 
advanced  pregnancy,  showing 
inclination  of  head  towards 
right  shoulder.  (Webster,  Text 
Book  of  Obstetrics,  Fig.  113.) 


the  symphysis  pubis,  or  that  an  os  uteri  situated  centrally  around 
the  axis  of  the  brim  is  divided  unequally  by  the  sagittal  suture,  the 
anterior  segment  being  the  larger. 

It  is  now  generally  held  that  the  Naegele-obliquity  is  not  a 
regular  occurrence  in  normal  labour,  and  it  is  quite  certain  that  it 
does  not  occur  in  such  a  uniform  and  marked  way  as  to  make  it 
deserve  to  be  ranked  with  the  five  important  movements  of  flexion, 
internal  rotation,  extension,  restitution,  and  external  rotation.  In 
the  case  of  contraction  of  the  conjugate  diameter,  however,  the 
Naegele-obliquity  is  often  marked,  and  the  cause  of  its  occurrence 
in  general  will  be  discussed  when  the  mechanism  of  labour  in  a 


The   Mechanism   of   Labour. 


265 


pelvis  contracted  in  its  conjugate  character  is  described.  Even, 
however,  when  the  pelvis  can  hardly  be  called  contracted,  whenever 
the  head  passes  with  difficulty,  and  has  prominent  and  firmly 
ossified  parietal  tubera,  so  that  the  bi-parietal  diameter  is  greater 
than  the  oblique  diameters  slightly  inclined  to  it,  some  degree  of 
Naegele-obliquity  is  common  throughout  the  earlier  part  of  the 
passage  of  the  head  through  the  pelvis.  It  has  then  the  mechanical 
advantage  that  the  large  bi-parietal  diameter  of  the  head  is  never 
opposed  to  any  diameter  of  the  pelvis,  but  one  parietal  tuber,  the 
anterior,  always  passes  a  little  in  advance  of  the  other. 


Fig.  175. — Diagram  to  show  synclytism  of  the  head. 

Whether  or  not  any  Naegele-obliquity  exists  in  the  earlier  part  of 
the  passage  of  the  head,  there  is  almost  invariably,  in  the  later  part 
of  the  passage  through  the  canal  of  soft  parts,  a  lateral  or  bi- 
parietal  obliquity  of  the  opposite  kind,  by  which  the  head  is  flexed 
towards  the  anterior  shoulder  (i.e.,  the  right  shoulder,  in  the  first 
position)  instead  of  the  posterior.  For  the  occiput  is  not  usually 
ever  rotated  quite  completely  to  the  front,  and  moreover  the  head 
meets  the  inclined  plane  of  soft  parts  (see  Fig.  131,  p.  220)  before 
even  the  full  amount  of  internal  rotation,  which  does  occur,  is 
finished.  The  inclined  plane  then,  its  resistance  being  directed 
forward — while  it  pushes  the  occiput  towards  the  child's  back  (in 
occipito-anterior  positions),  and  so  causes  extension — must  at  the 


266 


The   Practice  of   Midwifery. 


same  time  push  it  towards  the  anterior    shoulder,  and  so  cause 
lateral  flexion. 

Supposing  that  there  is  no  Naegele-obliquity  while  the  head  is 
passing  through  the  upper  part  of  the  pelvis,  this  lateral  flexion 
might  conceivably  take  place  rapidly  enough  to  keep  the  two 
parietal  tubera  on  the  same  level  in  reference  to  each  successive 
plane  of  the  genital  canal  of  soft  parts,  a  condition  called  by 
German  authors  the  synclitic  movement  of  the  head  (Fig.  175).     In 


Fig.  176. — Diagram  of  anterior  parietal  obliquity. 


point  of  fact,  however,  just  as  the  extension  of  the  head  is  not  rapid 
enough  to  prevent  the  presenting  point  moving  progressively  forward, 
relatively  to  the  head,  toward  the  posterior  fontanelle,  as  the  head 
approaches  the  outlet,  so  the  lateral  flexion  is  not  rapid  enough  to 
keep  the  parietal  tubera  on  the  same  level  in  reference  to  the 
successive  planes  of  the  genital  canal.  The  anterior  parietal  tuber 
therefore  almost  always  passes  each  plane  toward  the  outlet  of  the 
canal  somewhat  in  advance  of  the  posterior,  even  when  there  is  no 
Naegele-obliquity  in  the  upper  part  of  the  canal.  When  the 
Naegele-obliquity   does    exist   at   first,  this   advanced   position   of 


The  Mechanism   of   Labour. 


267 


the  anterior  tuber  will  be  the  more  marked,  because  the  left  lateral 
flexion  will  have  first  to  be  obliterated,  before  the  right  lateral 
flexion  can  be  produced. 

Similarly,  in  unreduced  occipito-posterior  positions,  a  lateral 
flexion  of  the  head  toward  the  anterior  shoulder  will  accompany  the 
movement  of  chin-flexion  by  which  it  escapes  under  the  pubic  arch. 
Some  authors  maintain  that  anterior  parietal  obliquity,  or  Naegele's 
obliquity,  is  most  likely  to  obtain  in  the  case  of  primiparse  in  whom 


Fig.  1 77. — Diagram  of  posterior  parietal  obliquity. 


the  tense  abdominal  walls  press  the  uterus  backwards,  so  that  its 
long  axis  is  behind  that  of  the  pelvic  inlet,  while  the  opposite  con- 
dition of  posterior  parietal  obliquity,  where  the  head  enters  the  brim 
obliquely,  so  that  the  posterior  parietal  bone  is  at  a  lower  level  than 
the  anterior,  is  most  generally  seen  in  multipara  with  lax  abdominal 
walls  and  a  tendency  to  a  pendulous  abdomen  (Figs.  176,  177). 

These  varieties  of  lateral  obliquity,  like  the  Naegele-obliquity,  are 
not  of  sufficient  importance  to  be  ranked  on  a  level  with  the  five 
main  rotations  as  already  enumerated. 


268  The  Practice  of   Midwifery. 

Moulding  of  the  Foetal  Head  in  Vertex  Positions. — Two 
changes  in  the  head  are  produced  by  the  pressure  on  it  during 
labour — first,  a  general  diminution  of  its  size  ;  and  secondly,  an 
alteration  in  its  shape,  by  which  the  diameters  most  compressed 
are  specially  diminished,  a  compensatory  increase  taking  place  in 
certain  other  diameters.  The  general  diminution  of  the  head  is 
produced  partly  by  some  of  the  blood  being  squeezed  out  of  the 
head  into  the  rest  of  the  body,  and  partly  by  some  of  the  cerebro- 
spinal fluid  being  squeezed  out  of  the  cerebral  ventricles  into  the 
spinal  canal.  Its  occurrence  is  proved  by  the  rapid  increase  which 
takes  place  in  the  average  diameters  of  the  head  during  a  day  or 


Fig.  178. — Moulding  of  head  in  occipito-anterior  position  of  vertex. 

two  after  birth,  a  period  during  which  the  whole  weight  of  the  child 
is  somewhat  diminishing.  The  diminution  is  rendered  possible, 
first  by  the  obliteration  of  any  interval  between  the  bones  which 
existed  along  the  sutures,  and  secondly  by  the  overlapping  of  the 
bones.  This  overlapping  takes  place  in  a  regular  way,  in  con- 
sequence of  the  anatomical  relations  of  the  bones.  Both  the  frontal 
and  occipital  bones  pass  beneath  the  parietal  bones,  thus  allowing  a 
diminution  in  the  antero -posterior  diameter  of  the  head.  The 
parietal  bones  also  overlap,  and  almost  invariably  the  posterior 
parietal  bone,  which  is  subjected  to  most  pressure,  passes  beneath 
the  anterior.  The  movement  of  the  occipital  bone  is  rendered 
possible  by  a  cartilaginous  interval  between  the  posterior  and  the 
basilar  portion,  so  that  the  posterior  portion  is  capable  of  a  kind  of 
hinge  movement  on  the  other. 


The   Mechanism  of   Labour.  269 

The  moulding  in  shape  of  the  foetal  skull  in  oceipito-anterior 
positions,  and  also  in  occipito-posterior  positions  which  end  by 
rotation  of  the  occiput  forward,  is  shown  in  Fig.  179.  The  con- 
tinuous outline  is  the  unmoulded  head  ;  the  dotted  outline  indicates 
the  shape  after  moulding.  The  points  f,  b,  o  in  the  figure  indicate 
definite  points,  namely,  the  root  of  the  nose,  and  the  centres  of  the 
anterior  and  posterior  fontanelles,  and  the  diameters  are  measured 
to  these  definite  points  (see  p.  131).  The  chief  diminution  is  in  the 
suboccipito-bregmatic  (s.o. — b)  and  suboccipito-frontal  diameters, 


X 

^ 

X 

'  ~~r 

/ 

1 

/^-^^ 

1 

i^TG.  179. — Moulding  of  head  in  oceipito-anterior  position  of  vertex.  (Aftei 
Budin.)  The  continuous  outline  shows  the  shape  of  the  head  before,  the 
dotted  outline  after,  moulding. 

which  are  successively  opposed  to  the  antero-posterior  diameter  at 
the  outlet.  The  fronto-occipital  diameter,  r  o,  is  also  diminished, 
and  even  the  mento-occipital  diameter,  m  o  (measured  to  the 
posterior  fontanelle),  is  somewhat  diminished,  instead  of  being 
increased,  as  might  at  first  sight  be  expected,  from  the  outward 
appearance  of  the  moulded  head.  The  chief  compensatory  increase 
is  in  the  maximum  oblique  or  vertico-mental  diameter  (m — x), 
which,  when  the  head  is  well  flexed,  lies  almost  in  the  axis  of  the 
genital  canal  at  the  point  where  the  centre  of  the  head  is  placed. 
In  the  unmoulded  head  the  posterior  extremity  of  this  is  much 
nearer  to  the  posterior  than  to  the  anterior  fontanelle  (see  x, 
Fig.  89,  p.  VAH),  )jut  after  moulding  it  runs  to  a  point  not  far  from 


270 


The  Practice  of   Midwifery. 


the   centre   of   the  sagittal  suture  (x,  Fig.  179).       It  will  be  ob- 
served that  the  change  of  shape  takes  place  not  so  much  by  the 


so 


Fig.  180. — Usual  moulding  of  head  in  unreduced  occipito-posterior  position 
of  vertex.  The  continuous  outline  shows  the  shape  of  the  head  before, 
the  dotted  outline  after,  moulding. 


Fig.  181. — Usual  moulding  of  head  in  unreduced  occipito-posterior  position 

of  vertex. 

movement  of  the  bones  upon  each  other  as  by  the  bending  of  the 
thinner  parts  of  the  bones,  more  especially  of  the  parietal  bones, 
the  curvature  of  which  is  greatly  altered. 


The   Mechanism  of   Labour.  271 

Besides  the  moulding  visible  in  the  antero-posterior  section,  the 
head  also  becomes  flattened  from  side  to  side,  the  bi-parietal 
diameter  being  especially  diminished.  The  head  viewed  from  the 
front  or  from  the  back  immediately  after  delivery  has  also  an 
unsymmetrical  appearance.  This  is  due  to  the  posterior  parietal 
bone,  which  has  sustained  the  greatest  pressure,  being  more 
flattened,  and  the  anterior  parietal  bone,  which  has  been  directed 
toward  the  free  space  of  the  vagina,  having  become  more  convex. 
Besides  the  asymmetry  due  to  pressure,  there  is  also  a  natural 
asymmetry  in  the  foetal  head,  which  has  already  been  mentioned 
(see  p.  130).  After  the  effect  of  moulding  has  passed  off,  as  it 
generally  does  in  a  few  days,  or  a  week  at  the  utmost,  this  natural 
asymmetry  may  become  appreciable. 

When,  in  an  unreduced  occipito-posterior  position,  the  head  is 
delivered  without  assistance  in  the  usual  way,  the  forehead  passing 
under  the  pubic  arch  while  the  occiput  sweeps  over  the  perineum, 
the  moulding  in  the  antero-posterior  section  is  very  different,  and  is 
represented  in  Figs.  180,  181.  Here  the  fronto-occipital  and  mento- 
occipital  diameters  are  much  more  shortened  than  in  the  usual 
position,  and  the  compensatory  increase  takes  place  not  in  the 
maximum  oblique  or  vertico-mental  diameter  (m — x,  Fig.  89,  p.  128), 
but  in  the  suboccipito-bregmatic  diameter  (s.o. — b),  which  in  the 
other  case  is  so  much  diminished,  and  in  the  vertical  or  cervico- 
bregmatic  diameter.  Sometimes,  however,  in  unreduced  occipito- 
posterior  positions,  the  head  is  delivered  in  quite  a  different  way. 
Extreme  flexion  takes  place  at  quite  a  late  stage,  so  that  eventually 
the  occiput  escapes  over  the  edge  of  the  perineum,  while  the  fore- 
head is  still  high  up  behind  the  pubes.  As  a  rule,  this  occurs  only 
with  a  dead  child,  with  which  a  more  excessive  moulding  of  the 
head  is  possible,  and  it  is  sometimes  promoted  by  delivery  with 
forceps.  The  kind  of  moulding  is  then  an  exaggeration  of  that 
which  occurs  in  occipito -anterior  deliveries,  as  shown  in  Fig.  179. 
The  elongation  of  the  head  along  the  maximum  diameter,  m — x,  is 
excessive,  the  head  is  extremely  flattened  by  the  pressure  against 
the  pubes,  so  that  there  is  an  almost  uniform  slope  from  the  face 
up  to  the  parietal  bones,  and  the  back  of  the  head  forms  an  almost 
vertical  line  with  the  neck.  Fig.  180  is  drawn  from  measurements 
taken  by  the  author,  so  as  to  correspond  with  Budin's  figures. 
The  figure  given  by  Budin  for  the  moulding  in  occipito-posterior 
positions,^  and  also  that  of  Tarnier  and  Chantreuil,^  represents  the 

1  De  la  Tete  du  Foetus  au  Point  de  Vue  de  robstdtrique,  Paris,  187(i,  PI.  XVIII. 

2  Tarnier  et  Cliantreuil,  Traitc'i  de  PArt  des  Accouchements,  Paris,  1882,  Vol.  I., 
p.  (582. 


272 


The  Practice  of   Midwifery. 


exceptional  case  just  mentioned,  and  not  the  usual  condition  for  a 
child  spontaneously  delivered  alive.  Figures,  however,  are  given  by 
Barnes  ^  and  Spiegelberg  ^  which  show  the  same  general  shape  of 
the  head  as  Fig.  180. 


Caput  Succedaneum. — In  addition  to  the  changes  in  the  bony 

cranium,  the  appearance  of  the 
head  is  altered  by  the  formation  of 
the  cajDut  succedaneum.  The  cause 
of  its  production  has  been  already 
mentioned  (see  p.  225).  If  a  caput 
succedaneum  is  formed  at  the  early 
stage  of  labour,  the  head  being  in 
the  first  position,  its  centre  is  near 
the  border  of  the  anterior  parietal 
bone  near  the  centre  of  the  sagittal 
suture  (1'4,  Fig.  182).  The  reason 
why  it  is  not  centrally  situated 
over  the  sagittal  suture,  even 
though  there  be  no  lateral  obliquity 
of  the  head,  is  because  the  anterior 
part  of  the  os  uteri,  looking  toward 
the  yet  imperfectly  dilated  vagina, 
is  less  supported  than  the  posterior. 
As  the  head  becomes  more  flexed 
in  advancing,  the  centre  of  the 
caput  succedaneum  (in  occipito- 
anterior positions)  gradually 
advances  nearer  to  the  posterior 
fontanelle.  It  is  in  this  later  stage 
of  labour  that  the  most  marked 
caput  succedaneum  is  generally 
formed,  and  it  may  then  project  an 
inch  or  more  from  the  level  of  the 
cranial  bones.  In  Fig.  182,  1*4, 
l'4fe,  1-46,  show  the  successive  positions  in  the  first  position  of  the 
head,  or  fourth  position  after  rotation,  2'3,  2'3h,  2-3&  in  the  second 
position,  or  third  position  after  rotation.  The  same  points  will  be 
approximately  the  successive  presenting  points  of  the  head  in  the 
two  positions,  if,  with  Matthews  Duncan,  we  define  the  presenting 


Fig.  182. — Diagram  showing  posi- 
tions of  centre  of  caput  succeda- 
neum in  the  several  positions  of 
the  vertex. 

1'4,  lib,  1-4&.  Successive  posi- 
tions of  centre  of  caput  succeda- 
neum in  first  position  of  the  vertex, 
and  in  fourth  position  after  rota- 
tion. 

2-3,  23b,  2-3b.  Successive  posi- 
tions of  centre  of  caput  succeda- 
neum in  second  position  of  vertex, 
and  in  third  position  after  rota- 
tion. 

3a.  Position  of  centre  of  caput 
succedaneum  in  unreduced  third 
position  of  vertex. 

ia.  Position  of  centre  of  caput 
succedaneum  in  unreduced  fourth 
position  of  vertex.  (After  Tyler 
Smith.) 


1  "  On  the  Varieties  of  Form  imparted  to  the  Foetal  Head,"  Trans.  Obst.  Soc.  London, 
1866,  Vol.  VII.,  p.  171. 

2  Lehrbuch  der  Geburtshiilfe,  p.  1.50. 


The  Mechanism  of   Labour.  273 

point  as  that  point  on  the  surface  of  the  head  through  which  the 
curved  axis  of  the  developed  genital  canal  passes.  If,  however,  we 
take  Tyler  Smith's  definition,  which  seems  a  preferable  one,  that  the 
presenting  point  is  that  point  of  the  head  which  is  most  centrally 
situated  in  the  os  uteri,  the  vagina,  and  the  ostium  vaginae  in  the 
successive  stages  of  labour,  then  in  the  first  stage,  before  full  dilata- 
tion of  the  OS,  the  presenting  point  will  be  a  point  on  the  sagittal 
suture,  provided  that  the  os  is  central  in  reference  to  the  axis  of 
the  brim,  and  there  is  no  Naegele-obliquity  of  the  head. 

In  unreduced  occipito-posterior  positions  the  centre  of  the  caput 
succedaneum  advances  forward  toward  the  anterior  fontanelle  as 
the  head  descends,  instead  of  approximating  to  the  posterior 
fontanelle.  Thus  in  some  cases  the  anterior  fontanelle  may  be 
almost  in  the  midst  of  the  caput  succedaneum.  In  Fig.  182,  1*4, 
4a  indicate  the  successive  positions  in  the  fourth  position  of  the 
head,  2"3,  3a  in  the  third  position. 

The  position  of  the  caput  succedaneum  will,  after  the  birth  of 
the  child,  in  many  cases  show  in  what  position  the  head  has  been 
delivered.  Both  the  size  of  the  caput  succedaneum  and  the  extent 
of  the  moulding  of  the  cranium  depend  upon  the  amount  of 
pressure  to  which  the  head  has  been  subjected,  in  conjunction  with 
the  duration  of  labour. 

The  caput  succedaneum  is  formed  by  effusion  of  serum  into  the 
cellular  tissue  of  the  scalp,  with  occasionally  slight  extravasations 
of  blood  at  various  points.  It  is  at  its  maximum  at  the  time 
of  delivery,  and  progressively  diminishes  from  that  time.  Its 
diagnosis  from  cephalhematoma,  formed  by  rupture  of  a  consider- 
able vessel,  will  be  considered  under  the  head  of  that  affection. 

Diagnosis  of  Cranial  Positions. 

By  Abdominal  Palpation. — The  position  of  the  fcetus  may 
generally  be  diagnosed  by  inspection  and  palpation  of  the  abdomen  ; 
and  it  is  advisable  to  make  this  the  first  step  in  the  examination 
of  the  parturient  woman.  The  patient  should  be  placed  in  the 
dorsal  position,  and  the  examination  should  be  made  in  the  absence 
of  a  pain. 

(1.)  The  examiner  stands  at  whichever  side  of  the  patient  is 
convenient,  facing  her  head.  By  inspection  and  palpation  of  the 
shape  of  the  uterus,  he  ascertains  whether  the  long  axis  of  the 
child  is  longitudinal,  oblique,  or  transverse  in  relation  to  the  axis 
of  the  uterus,  and  also  defines  the  upper  limit  of  the  fundus  of  the 
uterus  (Fig.  183). 

M.  18 


274 


The  Practice  of   Midwifery. 


(2.)  Having  found  that  the  long  axis  is  longitudinal,  he  places 
the  palms  of  his  two  hands  at  each  side  of  the  fundus,  and  ascer- 
tains which  foetal  pole  occupies  it.  The  breech  gives  the  sensation 
of  a  large,  irregularly  shaped,  nodular  body ;  the  head  that  of  a 
smaller,  round,  hard,  and  more  movable  body,  separated  from  the 
rest  of  the  body  by  the  groove  of  the  neck  (Fig.  184). 

(3.)  The  next  step  is  to  determine  the  direction  of  the  back  of 
the  child.     The  examiner  places  his  fingers  on  either  side  of  the 


Fig.  183. — Abdominal  palpation.     Manoeuvre  No.  1. 


abdomen  and  makes  gentle  but  deep  pressure.  On  one  side  he 
feels  the  back  as  a  firm,  uniform,  resistant  mass,  without  any 
marked  projections.  On  the  other  he  feels  the  limbs,  especially 
the  knees  or  feet,  as  multiple  nodules.  These  will  be  movable 
in  the  liquor  amnii,  if  the  membranes  are  still  unruptured,  and 
may  be  making  active  motions.  In  fat  women,  or  when  a  large 
quantity  of  liquor  amnii  is  present,  the  diagnosis  is  facilitated  if 
one  hand  makes  deep  pressure  while  the  other  is  palpating.  The 
position  where  the  foetal  heart  is  best  heard  will  give  confirmatory 
evidence,  for  this  position  is  on  the  side  toward  which  the  back  is 
directed,    except     in    the     case    of    face    presentation.      Having 


The   Mechanism  of   Labour.  275 

differentiated  the  back,  the  examiner  next  ascertains  if  it  is 
directed  forward,  backward,  or  transversely.  If  the  direction  is 
backward,  the  Hmbs  will  be  felt  over  a  wider  area  of  the  front  of 
the  uterus  than  usual,  the  back  over  a  less  wide  area,  and  the 
foetal  heart  is  likely  to  be  less  plainly  audible  than  usual  (Fig.  185). 
(4.)  The  examiner  grasps  the  lower  part  of  the  uterus,  just 
above  the  symphysis  pubis,  between  the  fingers  and  thumb  of  one 
hand,  or  between  the  fingers  of  his  two  hands.     If  the  lie  of  the 


Fig.  184.^ — Abdominal  palpation.     Manceuvre  No.  2. 

child  is  cephalic,  he  can  thus  ascertain  whether  the  head  is  engaged 
in  the  pelvis  or  not.  If  it  is  not  engaged,  it  is  felt  as  a  round, 
hard,  movable  body.  The  next  step  is  then  to  determine  the 
attitude  of  the  head.  If  palpation  shows  that  the  greatest  cephalic 
prominence  is  on  the  same  side  as  the  limbs,  the  presentation  is 
vertex.  If  the  reverse  is  the  case,  the  presentation  is  face.  In  the 
latter  case,  the  diagnosis  is  confirmed  by  the  foetal  heart  being 
most  plainly  audible  on  the  same  side  as  that  on  which  the  limbs 
are  felt  (Fig.  185). 

(5.)  If  the  head  is  found  to  be  engaged  in  the  pelvis,  the  examiner 
turns  so  as  to  face  the  patient's  feet.     With  three  or  four  fingers  of 

18—2 


276  The   Practice  of   Midwifery. 

each  hand  he  makes  deep  pressure  downward  at  each  side  of  the 
lower  segment  of  the  uterus,  in  the  direction  of  the  axis  of  the 
pelvic  brim.  He  finds  that  one  hand  is  arrested  sooner  than  the 
other  by  a  hard,  round  body,  the  head,  while  the  other  hand 
descends  deeper  into  the  pelvis.  In  vertex  presentations  the 
prominence  of  the  head  is  on  the  same  side  as  the  limbs,  in  face 
presentation    on    the    opposite    side.      The   depth   at   which   the 


1         I 
\ 


Fig.  185. — Abdominal  palpation.     Maneeuvre  No.  ,S,  "  Cephalic  grip." 

prominence  is  felt  indicates  the  degree  of  descent  of  the  head  into 
the  pelvis.  If  the  head  has  descended  deeply,  the  anterior  shoulder 
may  often  be  detected  by  this  method  of  palpation(Fig.  186). 

(6.)  In  cases  of  obstructed  labour  the  retraction  ring  may  be 
felt,  especially  during  a  pain,  as  a  transverse  depression  running 
across  the  front  of  the  uterus,  and  forming  the  lower  limit  of  the 
firm,  thick,  contracting  segment  of  the  uterus,  which  hardens 
during  the  pain. 

(7.)  The  round  ligaments  may  be  palpated  in  the  neighbourhood 


The  Mechanism   of   Labour.  277 

of  the  internal  inguinal  ring.  If  they  converge  towards  the 
uterus,  according  to  Palm  and  Leopold/  the  placenta  is  usually 
situated  on  the  posterior  wall  of  the  uterus.  If  they  are  parallel 
or  diverging,  it  is  usually  on  the  anterior  wall.  This  is  due  to  the 
fact  that  the  uterine  wall  to  which  the  placenta  is  attached  becomes 
more  developed  than  the  other.  The  degree  of  contraction  of  the 
ligaments  during  a  pain  is  an  indication  of  the  intensity  of  con- 
traction of  the  uterus  generally. 


/ 

;  1 

s 

\ 

\ 

%j   ; 

\ 

\ 

! 

"  ■'-    .1'-:'.'. 


Fig-.  186. — Abdominal  palpation.     Manoeuvre  No.  4. 

By  these  methods  of  abdominal  palpation  it  is  possible  to 
diagnose  the  presentation,  and  to  conduct  labours  in  the  majority 
of  cases  without  any  vaginal  examination  at  all.  Some  authorities 
advise  that  this  should  be  done,  in  order  to  avoid  the  risk  of  septic 
organisms  being  carried  by  the  examining  finger  into  the  vagina. 
The  drawbacks  are  that  the  stage  of  dilatation  of  the  os  cannot 
then    be   ascertained,    nor    the   progress    of   dilatation  ;    and   any 

'  I'alm,  "  IJebcr  dio  Diafj-nose  dcs  Placentarsitzcs  in  dcr  SchwaiiKerschaEt,"  Zeitsch. 
f.  Geb.  und  Oyn.,  IH'.KJ,  XX.V.  817—350;  liCopold,  "Die  Diagnose  des  riaceniar- 
Kitzes  in  dor  Scliwangerschaft  nnd  wiihrend  dei  Geburt,"  Arbeitcn  aus  des  Dresdener 
Fiauenklinik,  181).',,  IF.  151  — IGf;. 


278 


The  Practice  of   Midwifery. 


obstruction  to  labour  due  to  the  condition  of  the  cervix  or  vagina, 
or  a  prolapsed  funis,  would  remain  undiscovered  to  a  late  stage. 
Moreover,  those  not  very  dexterous  in  abdominal  palpation  might 
miss  the  diagnosis  of  occipito-posterior  positions  or  even  of  face 
presentation.  Although  it  is  impossible  theoretically  absolutely 
to  sterilise  the  hands,  it  is  found  practically  that  a  thorough  use 
of  efficient  antiseptics  is  a  sufficient  safeguard  in  ordinary  circum- 
stances against  the  conveyance  of  sepsis.  Whenever  it  is  necessary 
to  introduce  the  hand  into  the  interior  of  the  uterus,  during  or 
after   labour,  sterilised  rubber  gloves   should,  however,  be  worn. 


Fig.  188. — Second  vertex  position,  patient 
in  usual  obstetric  position. 


Fig.  187. — First  vertex  position,  showing 
relations  of  posterior  fontanelle  and 
sagittal  suture.  (Figs.  187,  188,  189 
and  190  from  Eden,  Manual  of  Mid- 
wifery, modified  from  Eibemont- 
Dessaignes  and  Lepage,  Precis 
d'Obstetrique.) 


In  all  cases,  too,  where  the  practitioner  has  under  his  care,  at 
the  time  he  is  attending  a  confinement,  a  septic  case  of  any 
description,  he  should  wear  sterilised  rubber  gloves  as  a  pre- 
cautionary measure,  even  when  making  vaginal  examinations. 


By  Vaginal  Examination. — Even  before  rupture  of  the  mem- 
branes, or  dilatation  of  the  os,  the  round  mass  of  the  head,  and  its 
separation  from  the  body  at  the  neck,  can  generally  be  made  out 
on  bimanual  examination  between  the  internal  and  external  hand 
through  the  uterine  wall,  the  patient  being  placed  in  the  dorsal 
position.  Examination  through  the  os  uteri,  to  determine  the 
presentation  and  position,  must  be  made  in  the  interval  of  pains. 


The   Mechanism  of   Labour. 


279 


while  the  membranes  are  lax.  The  head  is  distinguished  by  its 
hardness  and  uniform  outline.  Sometimes  the  yielding  portions  of 
the  bones,  on  being  impressed  with  the  tip  of  the  finger,  bend 
under  the  pressure  with  a  parchment-like  crackle,  which  can  be 
both  felt  and  heard.  After  the  rupture  of  the  membranes,  the 
accoucheur  may  often  determine  with  certainty  that  the  head  is 
presenting  by  feeling  the  hair  on  the  scalp. 

The  sutures  and  fontanelles  can  generally  be  made  out  before 
rupture  of  the  membranes,  but  more  easily  after  the  liquor  amnii 


Fig.  189. — Third  vertex  position.     Head 
flexed. 


Fig.  190. — Fourth  vertex  position.  Head 
partly  extended,  showing  anterior 
and  posterior  fontanelles  and  sagittal 
suture. 


has  escaped,  and  when  the  head  is  no  longer  covered  by  the  mem- 
branes. While  the  os  is  still  small,  it  is  probable  that  all  which 
can  be  detected  will  be  a  single  suture,  the  sagittal,  crossing  it 
generally  in  the  right  oblique  diameter,  approximating  nearer  to 
the  transverse  than  the  antero-posterior.  This  will  prove  that 
the  head  lies  either  in  the  first  or  third  position,  and  if  the 
direction  of  the  back  is  made  out  by  abdominal  examination,  it  is 
easy  to  decide  which  of  these  two  the  position  is.  Similarly,  if 
there  is  a  suture  running  in  the  left  oblique  diameter,  the  head 
must  be  in  the  second  or  fourth  position.  The  fontanelles  at  this 
early  stage  will  probably  be  about  equidistant  from  the  centre  of 
the  08,  covered  by  the  uterine  wall.  The  anterior  is  distinguished 
by  its  large  size,  and  the  four  sutures  at  right  angles  meeting  in 
it ;  the  posterior  by  its  small  size,  not  forming  any  actual  space, 


28o 


The  Practice  of   Midwifery. 


and  the  three  sutures  meetmg  in  it.  If  either  fontanelle  or  both 
can  be  reached,  the  position  of  the  head  is  deterrained  by  vaginal 
examination  alone.  The  direction  of  the  posterior  fontanelle  will, 
of  course,  give  the  direction  of  the  occiput. 

When  the  os  is  more  dilated,  and  the  head  has  descended  lower 
and  become  flexed  (in  occipito- anterior  positions),  the  posterior 
fontanelle  is  generally  reached  easily,  while  the  anterior  is  reached 
with  more  difficulty,  by  tracing  the  sagittal  suture  (see  Fig.  187, 
p.  278).  This  change  in  the  facility  of  reaching  the  two  fontanelles 
results  from  the  internal   rotation   of   the  head,    when   that  has 

progressed,  even  though  there 
should  be  no  increase  of 
flexion.  In  cases  of  some- 
what difficult  labour,  when 
flexion  is  very  great,  and  the 
head  large  and  much  elon- 
gated, the  posterior  fontanelle 
may  become  very  nearly  the 
presenting  point.  The  fon- 
tanelle may  be  obscured  by 
being  nearly  in  the  centre  of 
the  caput  succedaneum. 
Nothing  is  then  readily  made 
out  except  the  three  con- 
verging sutures.  When  the 
case  is  seen  for  the  first  time 
at  this  stage,  the  diagnosis  of 
the  position  of  the  head  is 
not  quite  so  easy,  from  the 
difficulty  of  telling  which  is 
the  occipital  bone.  The  anterior  fontanelle  may  be  reached  by 
passing,  if  necessary,  half  the  hand  into  the  vagina — the  right 
hand,  if  the  patient  is  lying  in  the  usual  left  lateral  position,  or  the 
left  hand,  corresponding  to  the  curve  of  the  genital  canal,  if  any 
difficulty  is  experienced.  In  some  cases  also  the  anterior  ear  can 
be  reached  without  much  difficulty,  especially  when  Naegele- 
obliquity  exists.  There  is,  however,  a  simple  and  easy  mode  of 
determining  the  point,  depending  upon  the  laws  of  the  moulding  of 
the  head,  according  to  which  the  occipital  always  passes  beneath 
the  parietal  bones.  If  it  can  be  ascertained  that  one  of  the  three 
bones  has  a  tendency  to  become  depressed  beneath  the  other  two, 
the  bone  is  certainly  the  occipital  bone,  and  the  direction  of  the 
occiput  is  tlins  determined. 


Fig. 


—  Moulding  of  head  showing 
posterior  parietal  bone  depressed  beneath 
anterior,  and  occipital  bone  beneath  both 
parietals.  (Kiberaont-Dessaignes  and 
Lepage,  Precis  d'Obstetrique,  Fig.  225.) 


The  Mechanism  of   Labour.  281 

Again,  in  occipito-posterior  positions,  as  the  head  descends  in 
•the  pelvis,  the  anterior  fontanelle  may  be  nearly  in  the  centre  of 
the  presenting  part,  and  the  posterior  fontanelle  may  be  difficult 
to  reach.  Then,  in  a  similar  way,  if  it  can  be  ascertained  that 
two  of  the  bones  tend  to  be  depressed  under  the  other  two,  these 
are  determined  as  being  the  two  segments  of  the  frontal  bone,  and 
the  position  of  the  head  is  thus  shown. 

A  criterion  is  given  for  distinguishing  occipito-posterior  from 
occipito-anterior  positions  even  before  the  opening  of  the  os.  This 
is  that,  in  occipito-posterior  positions,  the  anterior  segment  of  the 
uterine  wall  as  felt  from  the  vagina  does  not  descend  so  low  behind 
the  pubes  as  in  occipito-anterior,  because  the  forehead  does  not 
generally  lie  so  deeply  as  the  occiput  in  reference  to  the  plane  of 
the  brim.  This  criterion  is  not,  however,  always  decisive,  since, 
in  occipito-posterior  positions,  the  forehead  often  lies  lower  than 
usual  in  comparison  with  the  occiput. 

The  Third  Stage. — As  soon  as  the  child  is  expelled,  the  woman 
generally  has  a  feeling  of  intense  relief  and  comfort,  after  the  agony 
and  exertion  she  has  gone  through.  More  rarely  she  may  feel 
exhausted  or  faint,  or  a  rigor  may  occur. 

The  natural  course  of  the  third  stage  of  labour,  or  expulsion  of 
the  placenta,  is  rarely  seen,  since  it  is  usually  shortened  by  art. 
It  appears  that,  in  general,  the  placenta  is  detached,  partially  at 
any  rate,  almost  immediately  after  the  birth  of  the  child.  For, 
in  a  multipara,  and  where  there  is  no  obvious  laceration  of 
perineum  or  vagina,  the  first  appearance  of  blood  commonly 
indicates  that  some  separation  of  placenta  has  occurred.  Such 
appearance  of  blood  may  usually  be  noticed  very  quickly  after  the 
expulsion  of  the  child.  Moreover,  Lemser  examined  with  the 
entire  hand  in  168  cases  immediately  after  the  birth  of  the  child. 
He  found  that  in  71  per  cent,  the  lower  edge  of  the  placenta  could 
be  felt  lying  in  the  os  uteri  directly  the  hand  was  introduced,  and 
in  94  per  cent,  within  nine  seconds  after  delivery  of  the  foetus. 
On  the  other  hand,  in  the  uterus  removed  by  Porro's  operation, 
the  placenta  is,  in  most  cases,  found  completely  attached.  The 
vigour  of  the  contraction  and  retraction  of  the  uterus  must,  how- 
ever, be  impaired  by  the  incision  in  the  anterior  wall,  as  well  as  by 
the  effect  of  the  anaesthetic  given  to  full  surgical  degree.  The 
Porro  uterus  cannot  therefore  be  assumed  to  represent  the  normal 
condition. 

Mechanism  of  Detachment. — There  has  been  much  controversy  as 
to  the  mechanism  both  of  the  detachment  and  the  expulsion  of 


282 


The  Practice  of   Midwifery. 


the  placenta,  and  the  matter  is  not  yet  fully  settled.  One  cause 
is  almost  universally  acknowledged  to  be  a  valid  one,  and  by  some 
is  regarded  as  being  the  only  one,  namely,  the  shrinking  of  the 
placental  site  in  the  retraction  of  the  uterus.  On  this  subject  some 
facts  may  be  deduced  from  mechanical  considerations.  For, 
consider  the  condition  of  the  placenta  when  shrinking  of  the 
placental  site  has  occurred  a  little  short  of  that  necessary  to  cause 


Fig.  192. — Sagittal  section  showing  placenta  hi  utero  after  birth  of  child. 
Note  thinness  of  wall  of  uterus  at  placental  site,  and  folding  of  flaccid 
lower  uterine  segment.  No  separation  of  placenta  has  taken  place. 
(Modified  after  Pestalozza,  Anatomia  dell  'Utero  Umano :  Vallardi, 
Milano.) 


detachment.  First,  suppose  the  form  of  the  uterus  globular  ;  the 
effect  of  shrinking  will  then  be  independent  of  any  detrusion.  Any 
section  through  the  uterine  wall  and  the  placenta  will  form  an  arc 
of  a  circle  ;  and  detrusion  cannot  commence  until  the  placenta  has 
been  separated.  The  uterine  surface  of  the  placenta  will  be  com- 
pressed towards  the  centre  of  its  area,  owing  to  its  attachment  to 
the  shrunken  placental  site.  This  compression  toward  the  centre 
will  decrease  from  the  uterine  to  the  foetal  surface,  which  is  free. 
Hence  any  small  element  of  area  on   the  uterine  surface  of  the 


The   Mechanism  of  Labour.  283 

placenta  at  the  centre  will  be  subject  to  no  radial  tension.  Any 
other  small  element  of  area  will  be  subject  to  radial  tension  because 
it  will  be  drawn  toward  the  centre  by  its  attachment  to  the  uterine 
wall,  and  drawn  outward  by  its  connection  with  the  corresponding 
areas  of  the  substance  and  foetal  surface  of  the  placenta,  which  have 
not  been  drawn  so  much  inward  toward  the  centre.  At  the  same 
time  the  shrinking  of  the  j)lacental  site  will  be  resisted  by  the  attached 
placenta,  and  will  therefore  be  less  than  that  of  a  corresponding 
area  elsewhere  in  the  uterus.  The  radial  tension  will  increase  from 
the  centre  toward  the  circumference,  because  the  obliquity  of  lines 
joining  corresponding  areas  of  uterine  and  fcetal  surfaces  will 
increase,  the  foetal  surface  being  less  drawn  in  toward  the  centre 
than  the  uterine.  Moreover,  while  any  element  of  area  away  from 
the  border  is  supported  on  all  sides  by  other  elements  of  area,  an 
element  of  area  on  the  border  is  unsupported  on  the  outside.  For 
both  reasons,  separation  must  begin  at  the  circumference,  and 
spread  inward  toward  the  centre,  unless  the  placenta  is  more  firmly 
adherent  at  the  circumference  than  at  other  parts,  and  there  is  no 
evidence  that  it  is  so  as  a  general  rule.  This  reasoning  is  in 
accordance  with  the  result  of  experiments  made  by  sticking  a  disc 
to  an  elastic  surface,  and  then  letting  the  surface  retract. 

The  mechanism  is  somewhat  modified  if  the  retracted  uterus  is 
not  globular,  but  tends  to  adopt  its  natural  form  of  a  flattened 
pear-shape.  This  it  does  in  the  Porro  uterus,  and  probably  also 
in  normal  conditions,  to  some  extent  at  any  rate.  In  this  case,  if 
the  placenta  is  situated  on  the  anterior  or  posterior  wall,  reaching 
to  the  sides  and  summit  of  the  uterus  in  its  retracted  shape,  the 
sides  may  be  so  pressed  inward  by  the  uterine  contraction  as  to 
do  away  with  the  outward  radial  tensions  in  a  lateral  direction. 
Similarly  the  top  of  the  placenta  may  be  so  pressed  down  by  the 
fundus  uteri  as  to  do  away  with  the  upward  radial  tensions  in  its 
upper  half.  But  if  so,  the  placenta  having  been  already  compressed 
as  much  as  it  can  be,  the  same  force  will  be  transmitted  to  the 
lower  half,  and  will  there  increase  all  the  downward  radial  tensions, 
so  that  separation  will  commence  at  the  lower  border,  from  the  effect 
of  detrusion  in  addition  to  retraction.  There  can  be  nothing  in  the 
contraction  of  the  uterus  in  any  case  to  diminish  the  downward 
radial  tensions.  If,  on  the  other  hand,  detrusion  acts,  when  the 
placenta  has  not  been  compressed  to  the  maximum  degree  or  nearly 
so,  the  downward  pressure  may  separate  the  top  of  the  placenta 
first,  the  placenta  not  being  able  to  transmit  the  force  like  a  rigid 
body  to  its  lower  margin.  It  appears  probable,  therefore,  that 
shrinking  of  the  placental  site  and  detrusion  are  the  main  forces 


284 


The   Practice  of   Midwifery. 


concerned  in  the  detachment  of  the  placenta  at  its  commencement, 
and  that  in  most  cases  separation  commences  at  the  lower  margin. 
Any  morbid  adhesion  at  any  part  of  the  placenta  would,  of  com'se, 
modify  the  commencement  of  separation. 

When  separation  has  once  commenced,  some  blood  is  poured  out. 


Fig.  193. — Expulsion  of  placenta  from  upper  segment  into  lower  uterine 
segment  and  vagina.  The  fundus  uteri  is  elevated,  the  lower  segment 
elongated,  and  the  cord  has  descended.  (From  specimen  in  Univ.  Coll. 
Hosp.  Med.  School  Museum.) 


in  the  interval  of  pains,  between  the  separated  surfaces,  and  must 
tend  to  aid  the  further  separation,  if  the  membranes  are  still 
sufficiently  attached  to  prevent  its  flowing  away  at  the  sides. 
Schultze  considers  the  formation  of  this  retro-placental  haemafcoma 
to  be  the  main  cause  of  separation.  Matthews  Duncan,  on  the 
other  hand,  considered  that  it  had  no  place  in  the  normal  mecha- 
nism.    Probably  it  comes  into  play  in  cases  when  the  placenta  is 


The  Mechanism  of   Labour.  285 

attached  to  the  fundus  of  the  uterus,  and  plays  the  greater  part, 
the  less  active  and  contmuous  is  the  uterine  contraction  during  the 
third  stage  of  labour.  Some  have  attached  importance  to  the 
diminution  of  intra-uterine  pressure  after  delivery.  The  firmly 
adherent  j)lacenta  of  the  Porro  uterus  appears  to  disprove  this  as 
a  cause. 

Mechanism  of  ExpiUsion.  —  It  was  formerly   thought   that  the 
placenta  came  down  like  an  inverted  umbrella,  with  its  foetal  surface 
near  the  insertion  of  the  funis  foremost,  as  shown  in  Fig.  195,  p.  286. 
This  necessarily  implies  that  the  placenta  and  upper  part  of  bag  of 
membranes  are  first  inverted  by  a    considerable  effusion  of  blood 
behind  them,  and  that  the  uterus   afterwards  contracts  on   this 
effusion  of  blood,  and  drives  out  the  placenta  by  its  means  (see 
Fig.  193),     According  to  Matthews  Duncan,  however,  the  normal 
process  is  that  the  placenta  is  folded  or  rolled  together  by  the 
contracting  uterus  on  an  axis  corresponding  to  the  long  axis  of  the 
uterus,  and  that  it  presents  at  the  os  uteri  by  a  point  on  its  foetal 
surface  very  near  its  lower  margin,  the  lower  margin  having  been 
somewhat  inverted  by  the  traction  of  the  membranes  which  the 
placenta   has   to    drag  after   it    (Fig.  194,  p.  286).      As  it   passes 
through  the  vagina,  the  placenta  usually  becomes  further  inverted 
by  the  traction  of  the  membranes,  which  have  still  partially  to  be 
peeled  off  the  uterine  wall,  and  drawn  out  of  the  uterine  cavity. 
When,  however,  the  uterus  acts  well,  and  the  vagina  is  contractile, 
the  placenta  may  jDresent  even  at  the  vulva  by  a  point  on  or  near 
its  edge,  and  come  out  rolled  on  a  longitudinal  axis,  with  its  uterine 
surface  outermost.      In  this  mode  of  expulsion,  effusion  of  blood 
behind  placenta  and  membranes  is  not  necessary  to  the  mechanism, 
and  Matthews  Duncan  regarded  the  ideally  perfect  expulsion  as 
almost  unaccompanied  by  blood. 

More  recently,  other  authorities  have  advocated  the  correctness 
of  the  old  view.  The  point  is  of  practical  importance,  because  the 
modern  principle  that  traction  should  never  be  made  upon  the  cord 
is  mainly  based  upon  the  idea  that  such  traction  interferes  with 
the  normal  mechanism  of  delivery.  There  is  no  doubt  that,  if 
traction  is  made,  the  placenta  is  drawn  down  in  the  shape  shown 
in  Fig.  193. 

Champneys,^  in  70  cases,  marked  the  spot  on  the  placenta  which 
first  presented  at  the  os  uteri.  In  the  great  majority  of  cases  (all 
but  lOj  this  spot  was  on  the  foetal  surface  within  two  inches  from 
the  lower  edge.      In  16  cases  it  was  on  the  lower  edge,  or  amnion 

'   ••  .M'-ctiiiiiisin  of  the  'I'liinl  Stii;,'e  ol'  riabour,"  Trans,  Obst.  Soc.  London,  Vol.  XXIX. 
l>p.  117  arifl  lol. 


286 


The  Practice  of   Midwifery. 


below  the  lower  edge ;  in  23  cases  it  was  on  the  placenta  within 
one  inch  of  the  lower  edge.  In  two  cases  only  the  uterine  surface 
of  the  placenta  presented.  It  was  found  also  that  the  presenting 
part  varied  with  the  position  of  the  placenta.  The  higher  the 
placenta,  the  higher  the  presenting  point,  and  vice  versa. 

These  results  indicate  a  partial  and  progressive  inversion  of  the 
placenta  and  membranes  and  a  mode  of  delivery  intermediate 
between  that  described  by  Schultze  and  that  described  by  Matthews 
Duncan.  In  Champneys'  cases,  however,  the  woman  lay  on  her 
side,  and  no  stimulation  was  used  to  the  uterus  during  the  third 
stage  of  labour.  It  is  probable  that  the  mechanism  is  not  ideally 
perfect  under  these  circumstances.      So  far  as  can  be  inferred  from 


Fig.  19-1. — Delivery  of  placenta  accord- 
ing to  Matthews  Duncan. 


Fig.  195. — Delivery  of  placenta  accord- 
ing to  Schultze. 


the  customs  which  exist  among  savage  tribes,  the  primary  position 
for  labour  is  not  that  of  lying,  but  rather  squatting  as  for  defecation. 
The  delivery  of  the  placenta  is  assisted  by  pressure  by  the  woman's 
own  hands,  or  by  the  aid  of  her  friends,  and  she  may  even  stand  up 
to  squeeze  the  abdomen  in  the  third  stage  of  labour.  At  any  rate, 
the  frequency  with  which  the  intervention  of  the  accoucheur  is 
called  for  in  the  third  stage  shows  that,  under  our  present  civilised 
conditions,  its  mechanism  is  often  not  entirely  natural. 

My  own  observations,  in  cases  in  which  the  uterus  is  stimulated 
in  the  usual  way  by  the  hand  after  delivery  of  the  child,  lead  me 
to  support  Matthews  Duncan's  view  so  far  as  to  say  that  the  main 
folding  of  the  placenta,  when  it  passes  the  os  uteri,  is  generally  on 
a  longitudinal  axis,  though  the  presenting  point  is  often  further 
from  the  edge  than  is  represented  in  Fig.  194.  It  is  easily  shown 
by  experiment  that  the  placenta  will  pass  through  a  much  smaller 


The  Mechanism  of   Labour.  287 

ring  when  thus  folded  than  when  the  insertion  of  the  funis  comes 
first. 

It  is  obvious  that,  the  more  the  expulsion  is  effected  by  effusion 
of  blood,  the  more  nearly  the  mechanism  approximates  to  Schultze's 
view ;  the  more  it  is  due  to  uterine  contraction,  the  more  nearly 
it  approximates  to  Matthews  Duncan's  view.  It  will  generally  be 
agreed  that  the  latter  is  preferable.  The  conclusion  is  that  the 
usual  mode  of  expulsion  is  intermediate,  to  a  variable  extent, 
between  the  two  mechanisms ;  but  approaches  rather  to  that 
described  by  Matthews  Duncan  when  the  placenta  is  attached  to 
the  anterior  or  posterior  walls  of  the  uterus,  and  the  more  nearly 
so,  the  more  judicious  is  the  management  of  the  third  stage,  and 
the  more  vigorous  the  uterine  action,  while,  on  the  other  hand,  it 
approaches  to  that  described  by  Schultze  when  the  attachment  of 
the  placenta  is  at  the  fundus  of  the  uterus,  and  the  uterine  con- 
tractions are  less  active  and  continuous  during  the  third  stage  of 
labour. 

Separation  and  Expulsion  oj  Membranes. — It  has  already  been 
explained  (see  p.  217)  that  the  membranes  are  separated  from  the 
lower  segment  of  the  uterus  by  its  dilatation  to  form  a  canal  for 
the  foetus,  and  that  this  separation  is  necessary  for  the  formation 
of  the  bulging  bag  of  membranes.  By  the  retraction  of  the 
uterus,  after  delivery,  the  chorion  is  partially  but  not  entirely 
detached,  the  line  of  separation  passing  through  the  ampullary 
layer  of  the  decidua  {see  p.  106),  so  that  the  superficial  layer  of 
the  decidua  comes  away  with  the  chorion.  The  chorion  is  thrown 
into  fine  wrinkles,  being  detached  along  the  ridges  of  the  wrinkles, 
but  remaining  attached  along  the  furrows.  When  the  placenta  is 
detached,  the  blood  which  escapes  thereupon  tends  to  detach  also 
the  membranes  in  the  vicinity  of  the  placenta.  It  does  not,  how- 
ever, separate  the  whole  bag  of  membranes,  partly  because  its 
quantity  is  insufficient,  partly  because  it  begins  to  escape  externally 
as  soon  as  it  has  cleared  a  way  for  itself  to  the  os  uteri.  Then, 
when  the  placenta  is  expelled  by  the  contraction  of  the  uterus,  it 
drags  after  it  the  membranes,  completing  their  separation  from 
above  downwards,  and  usually  inverting  the  bag  of  membranes. 
When  there  is  sufficient  effusion  of  blood  behind  the  placenta  to 
invert  it,  as  in  Fig.  195,  this  blood,  driven  down  by  the  uterus,  aids 
in  the  inversion,  detachment,  and  expulsion  of  the  bag  of  membranes. 
By  the  time  the  placenta  and  membranes  escape  from  the  vulva  the 
membranes  are  inverted,  the  foetal  surface  of  the  amnion  being 
external,  and  the  placenta  is  often  inverted  also.  If  delivery  of 
the  placenta  is  aided  by  gentle  traction  on  the  edg§  whiQh  presents 


288  The  Practice  of   Midwifery. 

in  the  vagina,  it  generally  comes  down  with  the  uterine  surface 
outermost. 

The  large  arteries  and  veins  passing  to  the  placenta  are  of 
course  torn  across  as  soon  as  detachment  occurs,  and  some  bleeding 
takes  place  from  their  open  mouths.  This  is  the  source  of  the 
retro-placental  hematoma,  when  such  is  produced.  But,  unless 
"  there  is  uterine  inertia,  the  open  mouths  are  quickly  closed  by 
further  retraction  of  the  placental  site,  the  muscular  fibres  of  the 
middle  coat  of  the  uterus  interlacing  irregularly  around  the 
vessels.  After  a  time,  the  exact  duration  of  which  is  unknown, 
permanent  closure  is  secured  by  the  formation  of  thrombi  in  the 
vessels  beyond  the  constricted  part,  just  as  thrombi  are  formed 
in  any  other  vessels  the  current  through  which  is  arrested  by 
pressure  or  ligature.  Champneys  estimates  the  amount  of  blood 
escaping  as  six  ounces  before  the  delivery  of  the  placenta,  and  six 
ounces  enclosed  in  the  placenta  and  membranes.  As  in  his 
observations  the  uterus  was  unstimulated  during  the  third  stage 
of  labour,  the  woman  lying  on  her  left  side,  the  average  quantity, 
when  the  uterus  contracts  well,  is  probably  less,  amounting  to  some 
400  to  500  gms. 

Occasionally  the  placenta  is  expelled  into  the  vagina,  or  even 
externally,  by  the  same  pain  which  expels  the  foetus.  More 
frequently  there  is  a  rest  for  a  variable  time — perhaps  for  from 
twenty  minutes  to  an  hour,  or  even  longer,  in  the  absence  of 
external  stimulus.  During  this  time  the  uterus  may  be  felt 
moderately  hard,  and  still  reaching  up  to  some  height  in  the 
abdomen,  generally  about  up  to  the  umbilicus.  At  this  period,  as 
well  as  at  other  times,  rhythmic  contractions,  though  not  very 
marked,  take  place  in  addition  to  tlie  tonic  contraction,  and 
therefore  the  uterus  varies  in  hardness.  After  a  time  the  con- 
tractions again  become  stronger,  and  are  felt  as  pains,  although 
slight  as  compared  with  those  of  the  expulsive  stage.  With  these 
pains  a  little  blood  may  be  expelled,  and  hence  they  have  been 
called  "  dolores  cruenti."  They  have  the  effect  of  gradually 
completing  the  detachment  of  the  placenta,  if  that  is  not  com- 
pleted just  after  the  birth  of  the  child,  or  by  subsequent  effusion 
of  blood  behind  the  placenta,  and  at  length  of  expelling  it  from 
the  body  of  the  uterus  in  the  manner  already  described,  so  that 
it  lies  partly  in  the  flaccid  relaxed  cervix  and  partly  in  the  vagina. 
Its  expulsion  externally,  in  the  absence  of  assistance,  is  effected 
by  the  expiratory  muscles,  aided  by  the  muscular  walls  of  the 
vagina  and  cervix. 

After  delivery  of  the  placenta,  the  uterus  may  be  felt  in  the 


The   Mechanism  of   Labour.  289 

hypogasti'ium  as  a  comparatively  small  firm  ball,  varying,  however, 
considerably  in  size  in  different  women.  The  average  level  of  the 
fundus  may  be  taken  as  rather  more  than  five  inches  above  the 
pubes,  and  more  than  half-way  from  pubes  towards  umbilicus ;  but, 
when  the  uterus  is  large  or  rests  unusually  high  above  the  pelvis, 
it  may  reach  even  up  to  the  umbilicus  or  somewhat  higher ;  and 
its  height  may  be  as  much  as  seven  or  eight  inches  above  the  pubes. . 
Khythmic  contractions,  in  addition  to  the  tonic  contraction,  con- 
tinue to  take  place  in  it,  although  not  necessarily  felt  by  the  woman 
as  pains.  In  all  cases,  therefore,  it  varies  in  hardness,  and  this 
variation  must  not  be  considered  as  indicating  a  risk  of  haemorrhage, 
unless  either  the  relaxation  is  too  great  in  the  intervals,  or  gushes 
of  blood  take  place  with  the  contractions,  or  between  them. 

Duration  of  Labour. — Very  wide  differences  are  found  between 
the  duration  of  labour  in  different  women,  depending  partly  upon 
the  vigour  of  the  expulsive  forces,  partly  upon  the  presentation  of 
the  foetus,  the  relation  between  the  size  of  the  fcetus  and  the  canal 
of  the  bony  pelvis  and  the  soft  parts,  as  well  as  upon  the  dilatability 
of  these  latter.  The  first  stage  generally  occupies  at  least  three  or 
four  times  as  long  as  the  second,  and  in  multiparse  the  second  stage 
may  be  completed  by  a  very  few  pains.  In  primiparse  the  length 
both  of  the  first  and  of  the  second  stage  is  very  much  greater :  that 
of  the  first,  from  the  greater  rigidity  of  the  cervix ;  that  of  the 
expulsive  stage,  from  the  resistance  offered  first  by  the  orifice  of  the 
vagina,  formed  by  the  ring  of  hymen  so  far  as  it  still  exists,  which 
must  inevitably  be  more  or  less  lacerated,  and,  secondly,  by  the 
perineum,  which  has  never  before  undergone  dilatation. 

The  average  duration  of  labour,  reckoning  from  the  first  manifest 
pains,  may  be  taken  as  being  about  fifteen  hours  in  primiparse,  and 
seven  or  eight  hours  in  multiparse.  In  primiparse  beyond  the  age 
of  thirty-five  years,  the  duration  of  labour  is  greater,  and,  on  an 
average,  exceeds  twenty-four  hours. 

A  greater  number  of  labours  take  place  during  the  night  than 
during  the  day ;  the  hours  during  which  most  commence  being 
those  from  9  to  12  p.m.,  and  those  during  which  most  are  terminated 
those  from  midnight  to  3  a.m. 


M.  19 


Chapter  XIIL 

MANAGEMENT   OF  NORMAL  LABOUR. 

It  is  a  well-known  rule  that  the  accoucheur  should  always  attend 
promptly  to  the  first  summons  from  a  lying-in  woman.  It  may  be 
that  she  has  deferred  sending  till  the  last  moment,  or  labour  may 
be  extremely  rapid.  In  such  a  case,  if  from  any  delay  of  the 
attendant  the  child  is  born  before  his  arrival,  the  mother's  life  may 
be  lost  from  j^ost-jKirtum  haemorrhage,  or  the  child's  in  a  case  of 
pelvic  presentation.  Again,  the  favourable  moment  for  interference 
in  a  case  of  abnormal  presentation  may  be  lost.  If,  on  the  other 
hand,  the  patient  has  sent  unnecessarily  early,  the  attendant,  after 
ascertaining  the  exact  state  of  affairs,  and  the  probable  duration  of 
the  labour,  may  confidently  leave  her  for  a  time. 

Requisites  to  be  taken  by  the  Accoucheur. — The  attendant 
should  be  provided  with  a  stethoscope,  a  catheter  (either  a  glass 
female  catheter  or  a  No.  10  or  No.  12  gum-elastic  male  catheter), 
bottles  containing  chloroform,  ether,  solution  of  chloral,  tincture  of 
opium  or  Battley's  liquor  opii  sedativus,  liquor  ergotse  ammoniatus, 
or  some  preparation  of  ergot  for  hypodermic  injection,  such  as 
ergotinine  citrate  or  ernutine,  a  vaginal  douche  for  use  with  an 
ordinary  jug,  a  hypodermic  syringe  with  tablets  for  hypodermic  injec- 
tion, a  Schimmelbusch's  mask  or  Junker's  chloroform  inhaler,  and 
either  a  small  elastic  catheter  (No.  6)  suitable  for  passing  into  the 
infant's  larynx,  or  a  special  mucus  evacuator.  These  may  be 
carried  in  a  leather  bag  fitted  with  a  removable  sterilisable  linen 
lining  with  pockets  for  the  bottles.  There  should  also  be  in  the 
bag  a  Budin's  intra-uterine  tube,  a  perineum  needle,  silkworm  gut 
or  horsehair  for  stitching  the  perineum,  and  iodoform  gauze  for 
plugging  the  uterus.  A  pair  of  axis  traction  midwifery  forceps 
should  also  be  carried,  and  the  few  instruments  necessary  for  intra- 
venous transfusion  or  plugging  the  uterus,  viz.,  a  glass  cannula,  a 
scalpel,  scissors,  aneurism  needle,  two  pairs  of  Spencer  Wells' 
forceps,  a  pair  of  dissecting  forceps,  together  with  a  vulsellum  and 
a  pair  of  intra-uterine  or  ovum  forceps.  A  pair  of  thin  rubber 
gloves  should  never  be   omitted,  and   these,  as   well   as  all   the 


Management  of   Normal  Labour.  291 

other  instruments,  should  be  carried  in  Hnen  bags  which  can  be 
washed  and  steriHsed. 

There  should  be  provided  in  the  room  hot  and  cold  water, 
thread  for  tying  the  funis,  an  abdominal  binder,  absorbent  wool, 
and  a  supply  of  diapers,  or,  by  preference,  sterilised  pads  of  cotton 
wool  covered  with  gauze. 

Certain  antiseptics  must  either  be  carried  in  the  obstetric  bag,  or 
provided  beforehand  at  the  house.  These  are  alcohol,  70  to  80  per 
cent.,  perchloride  or  biniodide  of  mercury  for  disinfection  of  hands 
and  non-metallic  instruments,  and  either  lysol,  carbolic  acid,  or 
formalin  for  metallic  instruments.  Perchloride  and  biniodide  of 
mercury  may  be  carried  either  in  tabloids  or  in  solution.  If 
tabloids  are  used  they  should  be  tested  with  the  water  of  the  district 
in  dilute  solution,  to  make  sure  that  no  precipitate  is  formed  by  the 
hardness  of  the  water.  They  should  contain  no  powdery  colouring 
matter,  which  would  mask  the  slight  milkiness  caused  by  precipita- 
tion. A  concentrated  solution  can  be  made  according  to  the 
following  formula : — E.  Hydrarg.  Perchlor.  gr.  xx..  Acid  :  Hydro- 
chlor.  dil.  5ss.,  Glycerini  5i.,  Aq.  ad  ji.  The  acid  increases  the 
efficacy  of  the  mercury  in  the  presence  of  albuminous  matter.  A 
concentrated  solution  of  mercuric  iodide  may  be  made  according  to 
the  following  formula : — Pi.  Hydrarg.  lodid.  Eubr.  gr.  xx.,  Potass. 
lodid.  gr.  XV.,  Aq.  51.  Tabloids  are  also  made  of  it,  which  dissolve 
readily.  Pure  carbolic  acid  may  be  carried,  liquefied  by  10  per  cent. 
of  water. 

Antiseptic  Precautions. — The  reports  of  the  Registrar-General 
show  that  the  mortality  due  to  puerperal  septicaemia  throughout 
Great  Britain  considerably  exceeds  that  due  to  all  the  difficulties 
and  accidents  of  labour.  Hence  the  most  important  thing  of  all, 
in  the  conduct  of  normal  labour,  is  to  take  precautions  against  the 
occurrence  of  septicaemia.  Of  late  years,  by  the  improvement  of 
antiseptic  measures,  and  especially  by  the  use  of  perchloride  of 
mercury  as  an  antiseptic,  lying-in  hospitals  have  been  converted 
from  the  most  dangerous  places  of  all  for  delivery  into  the  safest. 
There  is  therefore  strong  reason  for  believing  that  a  universal 
adoption  of  stringent  antiseptic  precautions  would  considerably 
diminish  the  present  mortality  from  puerperal  septicaemia. 

I  may  so  far  here  anticipate  the  subject  of  puerperal  fever  as  to 
state  the  following  facts.  It  is  excessively  difficult  absolutely  to 
sterilise  the  vagina  by  any  antiseptic  treatment,  but  the  microbes 
or  germs  ordinarily  present  in  it  do  no  harm  unless  substances 
capable  of  decomposition,  such  as  placenta,  are  retained.     On  the 

19—2 


292  The  Practice  of   Midwifery. 

other  hand,  if  septic  microbes,  and  especially  if  virulent  microbes, 
are  introduced,  such  as  may  be  carried  from  puerperal  or  any  other 
form  of  septicaemia,  or  from  phlegmonous  erysipelas,  they  may 
cause  fatal  septicaemia  after  perfectly  normal  labour.  The  most 
important  element  of  antisepsis  therefore  consists  in  preventing 
the  introduction  of  virulent  germs  into  the  genital  canal,  and  this 
can  be  done  without  the  risk  of  injurious  effects  which  may  attend 
the  injection  of  poisonous  antiseptics. 

The  use  of  antiseptics  does  not  supersede,  but  supplements, 
ordinary  cleanliness.  Both  accoucheur  and  nurse  should  keep 
their  nails  short,  wear  no  rings,  and  scrub  their  hands  and  arms 
for  ten  minutes  before  touching  the  genitals.  The  hands  should 
then  be  disinfected  by  scrubbing  in  alcohol,  70  to  80  per  cent., 
and  then  in  a  solution  of  biniodide  or  perchloride  of  mercury,  1  in 
1,000.  A  basin  of  the  same  solution  should  be  kept  by  the  bed- 
side, that  the  hand  may  again  be  dipped  in  from  time  to  time. 
For  the  first  disinfection,  a  solution  of  biniodide  of  mercury  in 
spirit,  1  in  500,  is  also  most  effective.  The  nurse  must  use  the  same 
precautions  before  each  washing  of  the  genitals  after  labour.  If  a 
catheter  is  used,  it  should  be  a  glass  one,  sterilised  by  boiling.  If  a 
solution  of  1  in  1,000  is  found  to  roughen  the  hands  too  much,  one 
of  1  in  2,000  may  be  used.  Forceps  and  other  steel  instruments, 
after  thorough  cleansing  and  sterilisation  in  boiling  water,  are  best 
disinfected  by  a  solution  of  lysol  1  in  50,  of  formalin  5ss.  ad  Oi.,  or 
of  carbolic  acid  of  a  strength  of  at  least  1  in  40.  It  must  be 
remembered  that  soap  is  incompatible  with  most  antiseptics,  except 
lysol  or  carbolic  acid,  and  destroys  their  efficacy ;  also  that  a  very 
small  quantity  of  carbolic  acid  precipitates  the  sublimate  solution. 
Lysol,  being  alkaline,  has  in  itself  a  considerable  cleansing  as  well 
as  antiseptic  power,  and  may  be  used,  with  advantage,  for  the 
hands,  before  their  immersion  in  mercurial  solution.  Biniodide  of 
mercury  may  be  used  instead  of  the  perchloride,  and  is  even  more 
efficacious,  though  somewhat  more  expensive. 

It  is  most  important  that  the  practitioner  attending  midwifery 
cases  should  soil  his  hands  as  little  as  possible  with  infectious 
materials,  and  therefore  whenever  he  is  attending  any  septic  cases 
he  should  wear  rubber  gloves.  In  these  circumstances  he  should 
also  always  put  on  a  pair  of  sterilised  rubber  gloves  before  making 
any  vaginal  examination,  that  is  to  say  in  all  instances  where  his 
hands  have  come  in  contact  with  any  infectious  material,  such  as 
the  discharge  from  a  suppurating  wound.  The  external  genitals 
should  be  washed  by  the  nurse  with  soap  and  water  at  the  outset 
of  labour,  the  hair  cut  short  with   scissors,  and  then  the  parts 


Management  of   Normal  Labour.  293 

carefully  cleansed  with  an  antiseptic  solution,  since  pathogenic 
organisms  are  said  to  be  commonly  present  in  the  vulval  secretion 
though  not  in  the  vaginal.  Lysol  1  in  100,  which  is  valuable  for 
its  cleansing  quality,  may  be  used  first,  and  then  perchloride  of 
mercury  1  in  1,000,  which  is  less  irritating  to  skin  and  mucous 
membrane  than  the  alkaline  lysol. 

In  a  normal  case  it  is  neither  necessary  nor  advantageous  to  give 
a  vaginal  douche  before  labour,  but  if  any  purulent  vaginal  dis- 
charge is  present,  and  especially  if  there  is  any  suspicion  of  its 
being  of  gonorrhceal  origin,  a  douche  should  always  be  given  in  the 
early  stages  of  labour.  This  may  be  a  solution  of  perchloride  or 
biniodide  of  mercury  1  in  1,000,  or  lysol  1  in  100. 

After  delivery,  if  any  intra-uterine  manipulation  has  been 
carried  out,  or  if  there  is  any  other  reason  for  doing  so,  such  as 
haemorrhage,  an  intra-uterine  douche  of  perchloride  or  biniodide  of 
mercury  may  be  given  of  the  strength  of  1  in  4,000,  or,  better  still, 
of  lysol  1  in  100,  or  of  tincture  of  iodine  5ii.  to  the  pint,  or  of 
chinosol  1  in  400.  The  douche  should  be  given  at  a  temperature 
of  105°  to  110°  F.,  or  if  for  the  arrest  of  haemorrhage  at  a 
temperature  of  118°  to  120°  F. 

The  occasional  appearance  of  poisonous  symptoms  after  the  use 
of  mercury  has  generally  followed  the  repeated  use  of  the  solution 
rather  than  a  single  douche.  But  it  must  be  remembered  that 
immediately  after  delivery  is  the  time  when  there  is  the  greatest 
possible  extent  of  absorbent  surface.  If,  therefore,  a  mercurial 
douche  is  used  at  that  time,  special  care  must  be  taken  to  ensure 
that  it  flows  freely  away,  that  the  uterus  is  well  contracted  at  the 
time,  and  that  no  excess  of  it  remains  in  the  vagina  or  cervix.  On 
the  whole,  it  is  better  never  to  use  any  preparation  of  mercury  for 
an  intra-uterine  douche,  but  to  use  instead  a  solution  of  lysol. 

The  external  parts  should  be  washed  from  time  to  time  during 
the  progress  of  labour,  especially  if  it  be  prolonged,  with  pledgets 
of  wool  soaked  in  whatever  antiseptic  lotion  is  being  employed,  and 
it  is  well  to  keep,  as  far  as  possible,  a  sterile  pad  of  wool  or  one 
soaked  in  an  antiseptic  lotion  applied  to  the  genitalia  until  the  head 
is  engaged  in  the  vulva. 

Another  antiseptic  precaution  is  to  thoroughly  clear  out  the 
rectum  at  the  commencement  of  labour,  and  so  avoid  the  extrusion 
of  faeces  by  the  pressure  of  the  advancing  head.  This  is  best 
carried  out  by  the  administration  of  a  copious  enema  when  pains 
commence.  But  if  there  is  any  tendency  to  constipation,  a  daily 
action  of  the  bowels  should  be  secured  by  an  aperient  at  the  time 
when  labour  is  expected. 


294  The   Practice  of  Midwifery. 

It  is  improbable  that  sewer-gas  can  actually  originate  puerperal 
septicaemia.  But  it  may  be  a  predisposing  cause  by  depressing  the 
health  of  the  patient.  Care  should  be  taken  therefore  beforehand 
that  the  drains  of  the  house  are  in  good  order,  and  that  there  is  no 
concealed  water-closet  in  bedroom  or  dressing-room,  nor  any 
untrapped  waste-pipe  in  or  near  the  rooms. 

The  antiseptic  precautions  required  during  the  puerperal  period 
will  be  considered  later,  and  the  special  precautions  necessary  in 
lying-in  hospitals  will  be  discussed  under  the  head  of  puerperal 
septiccBmia  (Chapter  XXXIX.). 

Preliminary  Preparations. — The  room  should  be  as  airy  as 
possible  and  also  quiet.  The  bed  should  be  firm,  and  a  feather 
bed  is  especially  to  be  avoided.  The  bedding  and  bed  should  be 
protected  by  a  waterproof  sheet,  and  a  draw-sheet,  folded  in  several 
thicknesses,  should  be  placed  under  the  hips,  so  that  it  can  be 
readily  removed  when  soiled.  Special  lying-in  sheets  are  made, 
stuffed  with  sublimate  wood-wool.  These  have  the  advantage  over 
the  simple  draw-sheet,  since  they  are  capable  of  absorbing  a 
considerable  quantity  of  liquor  amnii  or  other  discharge.  With  the 
lower  classes  it  is  usual  to  wear  till  the  labour  is  completed  an  old 
suit  of  the  ordinary  dress,  including  stays,  which  interfere  with 
abdominal  examination.  It  is  preferable  for  the  patient  to  be  in 
her  night-dress,  over  which  she  may  wear  a  dressing-gown  in  the 
earlier  stages  of  labour.  It  is  a  good  plan  for  her  also  to  wear 
underneath  the  night-dress  a  special  petticoat,  fastened  loosely 
round  the  waist.  The  night-dress  can  then  be  tucked  up  and  kept 
clean  during  delivery,  and  when  the  labour  is  over,  the  soiled 
petticoat  can  be  easily  slipped  off,  and  the  necessity  for  changing 
the  night-dress  avoided.  With  the  poorer  classes  the  attendant 
should  insist  that  no  more  persons  than  necessary  are  in  the  room, 
since,  especially  among  the  Irish,  the  neighbours  are  fond  of 
gathering  in  the  lying-in  room. 

Position  of  the  Patient. — In  this  country  it  is  usual  for  the 
woman  to  lie  on  her  left  side,  with  the  hips  brought  near  the  edge 
of  the  bed,  during  the  later  stage  of  labour,  or  for  an  examination. 
On  the  Continent  and  in  America  the  dorsal  position  is  the  usual 
one.  Each  position  has  its  own  advantages,  but  on  the  whole 
those  of  the  lateral  position  predominate.  In  point  of  delicacy  it 
has  the  superiority ;  it  allows  forceps  or  other  instruments  to  be 
used  with  less  exposure  and  less  disturbance  to  the  patient ;  and  it 
tends    to    correct    the    common    right    obliquity    of    the    uterus. 


Management  of   Normal   Labour.  295 

Moreover,  during  the  passage  of  the  head  over  the  perineum,  the 
pressure  on  the  perineum  is  not  increased  by  the  weight  of  the 
child,  as  it  is  in  the  dorsal  position,  and  hence  the  risk  of  laceration 
is  somewhat  less  in  the  lateral  position.  On  the  other  hand,  the 
dorsal  position  tends  somewhat  to  accelerate  labour  during  the 
earlier  part  of  the  passage  of  the  head  through  the  pelvis.  Not 
only  does  the  weight  of  the  child  give  direct  assistance  to  the 
expulsive  force,  but,  by  pressing  the  presenting  part  more  firmly 
upon  the  os  uteri  or  vagina,  it  stimulates  the  contractions  of  the 
uterus  in  a  reflex  manner.  This  is  especially  useful  in  cases  of 
uterine  inertia. 

It  may  be  advantageous  to  vary  the  position  of  the  patient  from 
time  to  time  during  the  progress  of  the  labour  to  suit  varying 
conditions,  and  at  the  third  stage  the  patient  should,  as  a  rule,  be 
placed  upon  her  back. 

Examination  of  the  Patient. — The  first  object  is  to  ascertain 
whether  the  presentation  and  the  maternal  passages  are  normal. 
The  entrance  of  the  accoucheur,  however,  is  apt  to  put  a  stop  to 
the  pains  for  a  time,  and  he  should,  therefore,  be  careful  to  avoid 
startling  the  nerves  of  the  patient.  It  is  well  to  sit  down  quietly 
for  a  while,  ask  a  few  questions  about  the  time  when  the  pains 
commenced,  their  frequency,  character,  and  situation,  whether  any 
"  show  "  has  been  seen,  whether  the  waters  have  broken,  whether 
the  bowels  have  acted  freely,  and  also  to  feel  the  patient's  pulse. 
He  should  also  inquire  (if  he  has  not  previously  ascertained) 
about  the  character  of  former  labours,  the  state  of  health  during 
pregnancy,  and  whether  the  patient  has  reached  the  full  term. 
He  should  see  that  his  hands  are  warm  before  making  any  examina- 
tion. For  this  purpose  the  antiseptic  solution  for  disinfecting  the 
hands  should  be  used  hot. 

It  is  desirable  to  make  an  abdominal  examination  in  order  to 
ascertain  by  palpation  whether  the  uterus  and  foetus  are  naturally 
placed,  and  also  to  make  sure,  either  by  feeling  movements  or 
hearing  the  foetal  heart,  that  the  foetus  is  alive.  The  successive 
stages  of  abdominal  palpation  have  already  been  described. 
Abdominal  examination  is  more  troublesome  than  vaginal  when 
the  ordinary  dress  is  worn,  but  the  student  should  be  careful  to  use 
all  opportunities  both  of  practising  auscultation  of  the  foetal 
heart  and  acquiring  skill  in  making  out  the  parts  of  the  foetus 
and  its  position  by  abdominal  palpation.  He  should  not  scruple, 
therefore,  to  have  the  abdomen  fully  exposed. 

It  is  usual  and  preferable  to  commence  the  vaginal  examination 


296 


The  Practice  of   Midwifery. 


during  a  pain,  and  hence  arises  the  common  phrase  of  "  taking  a 
pain."  Her  attention  being  distracted  by  the  pain,  the  patient 
does  not  notice  so  much  the  inconvenience  of  the  introduction  of 
the  examining  finger.  The  index  finger  of  the  right  hand,  anointed 
with  an  antiseptic  lubricant,  such  as  lanocylhn,  or  glycerine  con- 
taining perchloride  of  mercury  1  in  1,000,  is  generally  used  for 
examination  in  the  position  shown  in  Fig.  196. 

The  vulvar  orifice  should  be  opened  with  the  fingers  of  the  left 


Fig.  196. — Exaraination  of  the  os  uteri  in  the  first  stage  of  labour. 


hand,  and  the  examining  finger  passed  directly  into  the  vagina  as 
far  as  possible  without  coming  into  contact  with  the  external 
genitalia. 

The  condition  of  the  vagina  may  first  be  noted,  especially  as  to 
its  freedom  from  any  obstruction  or  contraction,  the  relaxation  of 
the  mucous  membrane,  and  the  amount  of  lubricating  secretion 
present.  An  abundant  secretion  of  slimy  mucus  is  generally  a 
safe  indication  that  labour  has  set  in  in  earnest,  and  that  the  pains 
and  dilatation  of  the  os  will  progress  in  a  satisfactory  manner. 
For  the  physiological  relaxation  of  the  cervix,  generally  associated 
with  good  expulsive  pains,  is  usually  attended  also  by  a  copious 


Management  of   Normal  Labour.  297 

secretion  from  the  cervical  glands,  which  are  greatly  under  the 
influence  of  the  nervous  system. 

The  next  point  is  to  make  out  the  size  of  the  os  uteri,  and  the 
condition  of  its  edges.  The  inexperienced  student  must  be  careful 
definitely  to  feel  its  margin,  and  not  to  overlook  a  very  small  os, 
and  mistake  a  thin  uterine  wall  stretched  over  the  presenting  part 
for  the  bag  of  membranes.  If  the  os  is  still  small,  it  may  lie  so  far 
back  in  the  hollow  sacrum  as  to  be  difficult  to  reach.  In  such  a 
case  the  accoucheur  should  see  that  the  bladder  is  empty,  since  a 
full  bladder  displaces  the  cervix  much  farther  back,  and  should 
place  the  patient  on  her  back,  introducing  two  fingers  of  the  right 
hand  into  the  vagina,  and  pressing  the  fundus  downward  and  back- 
ward with  the  left  hand  placed  on  the  abdomen.  Another  plan,  but 
not  such  a  good  one,  is  to  place  the  patient  transversely  on  the  bed, 
still  lying  on  her  left  side,  and  introduce  two  fingers  of  the  left 
hand  into  the  vagina,  the  flexor  surfaces  directed  towards  the 
anterior  pelvic  wall.  Examination  while  the  pain  still  continues 
will  best  reveal  the  condition  of  the  os,  and  the  effect  of  the  pain 
upon  the  os,  the  bag  of  membranes,  and  the  presenting  part.  A 
thin  hard  margin  to  the  os  generally  denotes  that  dilatation  will  be 
slow,  or  that  the  stage  of  it  is  early  ;  if  the  edge  is  soft  and  thick, 
it  is  likely  to  yield  much  more  quickly. 

To  make  out  the  presenting  part,  if  the  membranes  are  still 
intact,  it  is  necessary  to  continue  the  examination  during  the 
interval  between  the  pains.  No  attempt  to  explore  it  should  be 
made  while  the  bag  of  membranes  is  tense,  lest  the  membranes 
should  be  ruj^tured  prematurely.  If  the  os  is  still  small  it  is 
sufficient  for  the  accoucheur  to  satisfy  himself  that  the  head  is 
presenting,  without  making  out  its  exact  position  by  feeling  the 
fontanelles.  To  do  this,  however,  it  is  not  sufficient  to  feel  the 
presenting  part  through  the  uterine  wall,  but  the  finger  must  be 
passed  in  through  the  os  to  touch  it.  If,  on  passing  the  external 
OS,  the  finger  finds  a  cervical  canal  still  existing,  so  that  the  bag 
of  membranes  or  presenting  part  does  not  rest  upon  the  external 
OS,  but  only  upon  the  internal  os,  or  upper  orifice  of  the  canal,  it 
is  generally  a  sign  that  the  labour  will  not  soon  be  over.  For  the 
internal  os  and  cervical  canal  have  to  be  dilated  before  dilatation 
of  the  external  os  begins,  and  this  process  is  indeed  often  completed 
during  the  few  days  before  active  labour,  while  there  are  still  no 
well-marked  pains. 

If  a  bag  of  membranes  only  is  felt,  and  no  presenting  part  can 
be  reached,  special  care  is  necessary  to  ascertain  whether  there  is 
any  abnormal  presentation,  especially  a  shoulder  presentation  or 


298  The   Practice  of   Midwifery. 

transverse  position  of  the  child.  In  this  investigation,  examination 
of  the  abdomen  should  on  no  account  be  omitted.  In  some  cases 
the  failure  to  feel  any  presenting  part  may  arise  simply  from  the 
liquor  amnii  being  very  abundant,  and  the  head  resting  far  forward 
above  the  symphysis  pubis,  not  engaged  in  the  pelvis.  In  such 
a  case  the  head  may  be  reached  by  pressing  the  finger  far  forward 
within  the  os,  while  the  patient  lies  on  her  back,  and  the 
external  hand  presses  the  head  down  from  above.  If  one  or  two 
fingers  fail  to  reach  any  presenting  part,  the  dilatation  of  the  os 
having  made  some  progress,  the  half-hand  or  whole  hand  should 
be  introduced  into  the  vagina  for  the  purpose,  an  anaesthetic  being 
given,  if  necessary. 

If  the  presenting  part  has  not  descended  into  the  pelvis  when 
the  first  examination  is  made,  and  particularly  if  no  guidance  is  to 
be  obtained  from  the  history  of  previous  labours,  the  size  of  the 
pelvis  should  be  explored  by  the  finger.  More  especially,  the 
accoucheur  should  test  whether  the  promontory  of  the  sacrum  can 
be  reached  too  easily,  and,  if  it  can,  he  should  measure  the 
diagonal  conjugate  diameter  (see  Chapter  XXIX.).  He  should  also 
judge  whether  there  is  less  space  than  usual  on  either  or  both 
sides  of  the  pelvis,  and  note  also  the  size  of  the  cavity  and  outlet. 
Next,  it  is  well  to  examine  whether  any  fseces  can  be  felt  in  the 
rectum ;  and  if  any  are  found,  to  have  an  enema  administered,  if 
labour  is  not  too  far  advanced,  or  too  rapidly  advancing.  A 
collection  of  faeces  in  the  rectum  may  materially  delay  the  progress 
of  labour  before  it  is  expelled  before  the  advancing  head.  Even  a 
small  quantity  of  faeces  interferes  with  perfect  antisepsis. 

As  to  the  probable  duration  of  labour,  the  medical  attendant 
may  form  an  opinion  for  his  own  guidance  from  the  size  and 
dilatability  of  the  os,  the  amount  of  mucus  present,  and  the  size 
of  the  pelvis.  He  should  avoid  risking  his  credit  by  making  any 
positive  prophecy  as  to  time  to  the  patient  or  her  friends,  but 
should  content  himself  with  assuring  her  that  all  is  going  well,  and 
that  the  duration  of  labour  will  depend  upon  the  pains.  As  to 
whether  or  not  it  is  necessary  for  him  to  remain  continuously  in 
attendance,  he  will  judge  partly  by  the  state  of  the  os,  partly  by 
the  vigour  and  frequency  of  the  pains,  taking  also  into  account 
whether  the  patient  is  a  primipara  or  a  multipara.  In  any  case  of 
doubt,  he  should  wait  for  at  least  half  an  hour  or  an  hour,  to 
watch  the  rate  of  progress.  Sometimes  a  patient  may  send  for 
her  attendant  when  suffering  only  from  false  pains,  that  is  to  say, 
irregular  and  painful  contractions  of  the  uterus,  which  do  not 
dilate  the   os.      False    pains    generally    recur    at   very   irregular 


Management  of   Normal  Labour.  299 

intervals,  not  with  the  more  or  less  rhythmic  regularity  of  true 
pains.  But  we  can  positively  distinguish  them  only  by  making 
a  vaginal  examination,  and  finding  that  they  do  not  produce 
dilatation  of  the  os,  or  cause  protrusion  of  the  bag  of  membranes. 
False  pains  commonly  depend  on  some  irritation  in  the  alimentary 
canal,  and  are  best  treated  by  a  mild  aperient  combined  with  a 
sedative,  such  as  hyoscyamus. 

Management  of  the  First  Stage — During  the  first  stage  the 
patient  should  not  be  kept  too  much  in  one  position.  It  is 
generally  better  that  she  should  be  up,  occasionally  walking  about, 
and  occasionally  resting  in  a  chair.  If  the  first  stage  is  tedious, 
the  lateral  position  is  especially  to  be  avoided,  because,  in  that 
position,  the  weight  of  the  ovum  is  taken  off  from  the  os  and  cervix, 
and  the  reflex  stimulus  is  thereby  diminished.  If  she  lies  down, 
the  patient  should  rather  lie  on  her  back.  At  this  stage,  she 
should  be  enjoined  not  to  weary  herself  with  bearing-down  efforts, 
which  at  present  are  useless,  and  her  strength  should  be  kept  up 
by  a  sufficient  amount  of  light  nourishment.  With  the  lower 
classes  it  is  often  necessary  to  discourage  the  use  of  alcohol. 
During  the  dilatation  stage  examinations  should  only  be  made  if 
absolutely  necessary.  Asa  general  rule,  in  the  conduct  of  a  case  of 
normal  labour  only  two  internal  examinations  should  be  made,  one 
during  the  first  stage  and  another  immediately  after  the  rupture 
of  the  membranes,  because  the  presentation  may  be  changed  with 
the  rush  of  liquor  amnii,  or  the  funis  may  become  prolapsed. 
Frequent  examinations  before  the  stage  is  reached  at  which  the 
abundant  secretion  of  mucus  begins  are  apt  to  irritate  the  cervix 
and  vagina,  and  increase  the  dryness  of  the  canal. 

If  the  attendant  remains  during  a  prolonged  first  stage,  he 
should  remember  not  to  stay  too  continuously  in  the  room,  but 
give  the  patient  opportunities  to  empty  her  bladder.  Occasionally 
difficulty  of  micturition  arises  from  the  pressure  of  the  head  on 
the  neck  of  the  bladder  or  urethra,  and  the  use  of  the  catheter 
may  be  necessary.  A  distended  bladder  may  be  a  cause  of  pro- 
longation of  labour,  from  its  interfering  with  the  effective  action 
of  the  auxiliary  muscles.  With  the  elongation  of  the  cervix  and 
distensible  lower  segment  of  the  uterus,  the  upper  part  of  the 
bladder  is  carried  upward  above  the  level  of  the  pubes  (see 
Fig.  131,  p.  220).  Hence,  if  an  abdominal  examination  be  made, 
the  bladder,  if  at  all  distended,  is  readily  felt  as  an  elastic  rounded 
swelling  in  front  of  the  lower  portion  of  the  uterus.  For  emptying 
the  bladder  a  full-sized   male   gum  elastic   catheter   (No.    10   or 


300  The  Practice  of   Midwifery. 

No.  12)  is  generally  preferable  to  the  short  glass  female  catheter, 
since  the  urethra  may  be  lengthened  and  distorted  by  the  dis- 
placement of  the  bladder  upwards,  and  the  pressure  of  the  head ; 
and  it  is  not  sufficient  to  reach  the  flattened  lower  portion  of  the 
bladder  in  order  to  evacuate  the  urine.  The  swollen  meatus  is 
also  apt  to  be  displaced  further  forward  than  its  usual  position. 
Difficulty  sometimes  arises  in  getting  the  point  of  the  catheter  past 
the  head.  One  or  two  fingers  should  then  be  passed  into  the 
vagina,  and,  by  pressure  forwards  through  the  urethral  wall,  the 
point  of  the  catheter  should  be  guided  up  to  and  past  the  point  of 
compression.  If  necessary,  the  head  should  be  pushed  somewhat 
backward  in  the  interval  of  a  pain,  to  give  the  catheter  room 
to  pass. 

Artificial  Rupture  of  Membranes. — When  the  dilatation  of  the 
OS  is  complete,  labour  is  accelerated  by  artificial  rupture  of  the 
membranes  (see  p.  226).  The  risk  is  also  by  this  means  averted 
that  the  amnion  may  be  separated  from  the  chorion  by  too  far  an 
advance  of  the  bag  of  membranes  in  front  of  the  head,  and  that  the 
chorion  may  consequently  be  left  behind  in  utero.  The  experienced 
practitioner  may  often  with  advantage  rupture  the  membranes 
rather  before  the  os  is  fully  dilated  to  the  size  of  the  vagina  or 
that  of  the  greatest  diameter  of  the  head,  but  not  before  it  is  large 
enough  for  the  head  to  enter  it  sufficiently  to  form  a  dilator  not 
less  efficient  than  the  bag  of  membranes.  If  the  membranes  are 
ruptured  prematurely,  the  os  is  apt  to  remain  rigid,  and  a  labour, 
which  had  been  progressing  favourably  up  to  that  point,  may  pass 
into  an  inactive  stage.  The  inexperienced  student  should  rather 
incline  to  the  alternative  of  leaving  the  membranes  too  long  intact 
than  to  that  of  rupturing  them  too  early.  The  bag  of  membranes 
may  generally  be  ruptured  by  pushing  the  tip  of  the  forefinger 
through  it  when  rendered  tense  by  a  pain.  If  the  membranes  are 
too  tough  to  allow  this,  they  should  be  gradually  scratched  through 
with  the  finger  nail,  while  still  tense.  If  this  still  fails,  they  may 
be  ruptured  by  pressing  upon  them  with  some  pointed  instrument. 
A  catheter  stylet,  or  uterine  sound,  is  preferable  to  the  traditional 
hairpin,  often  used  for  this  purpose,  and  care  must  be  taken  to 
sterilise  whatever  instrument  is  used.  Sometimes  there  may  be  so 
little  bulging  of  the  bag  that  it  is  difficult  to  judge  whether  the 
membranes  are  ruptured  or  not.  This  may  be  due  to  scantiness  of 
liquor  amnii,  or  to  the  membranes  being  inelastic  and  remaining 
adherent  near  the  margin  of  the  os.  In  such  a  case  the  distinction 
may  be  made  by  the  contrast  of  the  smooth  surface  of  the  membranes 


Management  of   Normal  Labour.  301 

with  the  roughness  due  to  the  hair  on  the  scalp.  Sometimes,  by 
sweeping  round  the  forefinger  an  inch  or  two  within  the  margin  of 
the  OS,  the  membranes  may  be  separated,  and  the  bulging  bag 
allowed  to  form.  In  rupturing  the  membranes  artifiicially,  especially 
if  liquor  amnii  appears  abundant,  it  is  a  good  plan  to  place  a  bed- 
pan or  bed-bath  under  the  patient,  to  prevent  her  getting  wetted. 
Otherwise,  the  excess  of  fluid  should  be  mopped  up  with  napkins, 
and  the  draw-sheet  shifted  to  a  dry  place. 

Management  of  the  Second  Stage. — Toward  the  end  of  the  first 
stage  the  patient  should  lie  down  in  the  left  lateral  position.  To 
aid  the  expulsive  pains,  it  is  usual  to  tie  a  round  towel  to  the  foot 
of  the  bed,  so  that,  by  pulling  upon  it  during  the  pain,  the  patient 
may  gain  some  assistance  in  fixing  her  chest  for  the  action  of  the 
auxiliary  muscles.  Women  often  like  also  to  be  able  to  rest  their 
feet  against  the  foot  of  the  bed.  As  soon  as  the  membranes  are 
ruptured  the  exact  position  of  the  head  should  be  made  out  by  the 
sutures  and  fontanelles,  if  this  has  not  been  done  previously,  so  that, 
in  case  of  occipito-posterior  positions,  the  management  presently  to 
be  described  may  be  carried  out.  In  general,  women  instinctively 
hold  their  breath,  and  bring  the  auxiliary  muscles  into  action  during 
the  expulsive  pains.  Sometimes,  however,  especially  in  the  case 
of  sensitive  women  who  feel  the  pains  acutely,  their  efficacy  is 
diminished  by  lack  of  closure  of  the  glottis.  In  such  a  case,  the 
woman  must  be  repeatedly  exhorted  not  to  cry  out  in  the  pain,  but 
to  hold  her  breath  and  bear  down.  The  giving  a  little  chloroform 
during  the  pain,  short  of  anaesthesia,  may  assist  towards  this  object. 
The  patient  need  not  be  kept  rigidly  in  the  lateral  position.  If  the 
uterus  is  inert  during  the  earlier  part  of  the  passage  of  the  head,  it 
is  of  advantage  to  place  her  on  her  back,  and  so  increase  the  reflex 
stimulus  due  to  pressure  of  the  head. 

Management  of  Occipito-posterior  Positions.— If  a  diagnosis 
of  the  position  of  the  head  is  made  in  occipito-posterior  positions, 
it  is  almost  always  possible  to  secure  by  manipulation  that  rotation 
of  the  occiput  forwards  which  fails  in  about  4  per  cent,  of  the  cases 
left  to  nature.  It  has  already  been  explained  that  failure  of  rota- 
tion is  always  due  to  insufficient  flexion  (see  p.  260).  Hence  the 
effort  should  be  to  promote  flexion  rather  than  to  attempt  the  more 
difficult  task  of  directly  rotating  the  head.  This  is  to  be  done  by 
pressing  on  the  forehead  with  one  or  two  fingers  during  the  pains, 
and  endeavouring  at  the  same  time  somewhat  to  aid  its  rotation 
backwards.      The  physician  may  also,  if  he  can  readily  accomplish 


302  The  Practice  of   Midwifery. 

it  in  the  intervals  between  the  pains,  pass  two  fingers  over  the 
occiput  and  endeavour  to  draw  it  downwards  and  forwards.  It 
must,  however,  be  borne  in  mind  in  these  cases  that  rotation 
forwards  often  occurs  very  late  in  the  course  of  labour,  and  prema- 
ture interference  is  to  be  deprecated.  If  the  attempt  to  promote 
flexion  fail,  then  the  case  may  be  either  treated  by  the  application 
of  forceps  or  vectis  or  the  hand  passed  into  the  vagina,  the  head  seized 
between  the  fingers  and  thumb,  and  the  occiput  manually  rotated 
to  the  front.  In  order  to  facilitate  this  manoeuvre,  the  head  should 
be  flexed  and  pushed  up  out  of  the  pelvic  cavity.  At  the  same 
time,  by  abdominal  manipulation,  an  attempt  should  be  made  to 
rotate  the  shoulders,  so  as  to  render  the  rotation  forwards  of  the 
occiput  a  permanent  one.  This  method  succeeds  in  the  great 
majority  of  the  cases.  Rotation  cannot  however  be  expected  to 
occur,  and  it  is  therefore  useless  to  attempt  to  promote  it,  until  the 
OS  is  sufficiently  dilated  to  allow  the  occiput  to  pass  over  its  margin, 
and  meet  the  resistance  of  the  pelvic  floor.  The  treatment  of 
protracted  labour  in  occipito-posterior  positions  by  the  aid  of  the 
vectis  or  force]3S  will  be  considered  in  the  chapter  on  the  use  of 
those  instruments  (ChajDter  XXXIII.). 

Preservation  of  the  Perineum. — When  the  head  begins  to  press 
upon  the  perineum,  the  physician  has  a  much  more  important  duty 
to  perform  than  in  the  earlier  stages  of  its  passage ;  and  by  skilful 
management  he  can  do  very  much  to  avert  laceration,  more  especi- 
ally in  the  case  of  iDrimiparse,  with  whom  the  risk  of  such  laceration 
is  much  greater.  The  plan  formerly  recommended  was  to  "  support 
the  perineum,"  that  is  to  say,  to  press  with  the  palm  of  the  hand 
upon  the  perineum  when  stretched  over  the  advancing  head,  and  so 
check  that  advance.  It  is  now  generally  agreed  that  such  pressure 
on  the  perineum  is  a  stimulus  to  increased  uterine  action,  and  so, 
when  pains  are  violent,  may  actually  bring  about  the  accident  which 
it  is  desired  to  avoid.  In  other  cases  again,  the  plan  of  prolonged 
pressure  led  to  quite  an  unnecessary  delay  in  the  j)assage  of  the  head. 

The  causes  which  chiefly  tend  to  rupture  of  the  perineum,  and 
which  are  capable  of  being  modified  by  art,  are  two  : — first,  and 
chiefly,  the  head  being  forced  through  the  outlet  by  vigorous  pains 
before  the  perineum  has  had  time  to  dilate  in  the  natural  manner 
under  the  influence  of  repeated  jDains ;  secondly,  the  fact  that  the 
uterine  force  transmitted  to  the  condyles  does  not  act  in  the  axis 
of  the  outlet  of  soft  parts  (see  Fig.  22,  p.  21,  and  Fig.  181,  p.  220), 
but  is  inclined  at  an  angle  toward  its  posterior  wall,  so  as  to  cause 
special  pressure  upon  the  perineum. 


Management  of   Normal  Labour.  303 

Hence  there  are  two  great  aims  to  be  carried  out  in  trying  to 
avoid  rupture,  first,  to  delay  the  too  rapid  advance  of  the  head  ; 
and  secondly,  to  press  it  forward  toward  the  pubic  arch,  and  so 
equalise  the  pressure  on  the  ring  of  the  vulval  outlet.  To  do  this 
both  hands  should  be  employed,  and  in  all  cases  the  physician 
should  determine  by  visual  insj)ection  the  degree  of  tension  which 
the  perineum  is  undergoing.  The  fingers  of  the  left  hand  passed 
between  the  thighs  from  the  front  may  be  placed  on  the  occiput  to 
check  its  advance  when  the  tension  becomes  too  great.   At  the  same 


\ 

s. 


Fig.  197. — Supporting  the  perineum  and  checking  the  advance  of  the  head  in 
the  manner  described. 

time  the  right  hand  is  spread  out  flat  behind  the  perineum,  so  that 
the  index  fingers  and  thumb  press  on  the  frontal  protuberances  a 
little  anterior  to  the  sacro-sciatic  ligaments  on  each  side,  and  direct 
the  head  forward,  without  exercising  any  pressure  on  the  sensitive 
central  portion  of  the  perineum  where  the  strain  is  greatest. 
Thus  both  hands  act  together  in  checking  advance  when  necessary, 
while  the  right  hand  keeps  the  head  forward  against  the  pubic  arch. 
At  the  same  time  that  he  employs  pressure  the  physician  may 
exercise  some  control  over  the  "  safety-valve  "  action  of  the  glottis 
by  telling  the  patient  to  cry  out,  and  to  cease  bearing  down,  when 
tension  Ijecomes  dangerous.     If  the  patient  is  devoid  of  self-control, 


304 


The  Practice  of   Midwifery. 


and  the  pains  tumultuous,  there  is  a  better  chance  of   avoiding 
laceration  if  chloroform  is  administered. 

In  primiparse  there  is  an  inevitable  laceration  of  the  entrance  of 
the  vagina  proper,  marked  by  the  remnant  of  the  hymen,  and  from 
this  point  the  laceration  may  run  upward  and  downward,  extending 
through  to  the  skin.  But  in  general  lacerations  reaching  the 
cutaneous  surface  of  the  perineum  run  from  before  backward,  com- 
mencing at  the  fourchette,  after  the  inevitable  laceration  has 
already  occurred,  if  the  patient  be  a   primipara.      It    is  to  the 


Fig.    198. — Expulsion  of   shoulders.     (Modified   from    Bumm,    Grundriss   der 
Geburtshilfe,  Fig.  215.) 


anterior  edge  of  the  perineum,  therefore,  that  attention  must  be 
most  closely  directed. 

It  is  not  uncommon,  however,  to  see  the  superficial  layers  of  the 
epidermis  cracking  and  giving  way  before  the  deeper  layers.  By 
pressure  in  front  of  the  sacro-sciatic  ligaments,  or  by  pressure  on 
the  fundus  uteri,  it  is  often  possible  to  squeeze  out  the  head  in  the 
interval  of  pains,  and  this  plan  is  a  good  one  when  the  pains  are 
difficult  to  control. 

The  treatment  required  for  a  distinctly  pathological  rigidity  of 
the  perineum  will  be  considered  in  Chapter  XXVII. 


Expulsion  of  the  Trunk. — As  the  head  is  passing  through  the 
vulva,  the  patient's  right  thigh  should  be  raised  by  the  nurse,  to 
allow  the  occiput  to  pass  forward  in  front  of  the  pubes.     The  head 


Management  of   Normal  Labour.  305 

should  be  received  upon  the  right  hand,  and  by  it  guided  forward 
close  to  the  thighs,  as  the  trunk  is  expelled. 

As  soon  as  the  head  has  passed  the  vulva,  the  physician  should 
see  if  the  funis  is  round  the  neck,  and  if  it  is,  he  should,  as  quickly 
as  possible,  slip  the  loop  over  the  head.  If  he  cannot  do  this  he 
should  try  to  slip  it  over  the  shoulders.  If  this  also  fails  the  funis 
may  be  rendered  so  short  that  it  checks  the  further  advance  of  the 
child,  and  the  child  will  then  be  in  danger  of  asphyxia  from  the 
funis  being  drawn  tight,  and  the  circulation  through  it  stopped. 
If,  therefore,  the  funis  is  found  to  be  tight,  and  cannot  be  released, 
it  should  be  cut  with  scissors,  the  child  quickly  extracted,  and 
the  ]3roximal  end  of  the  funis  held  between  the  finger  and  thumb  to 
prevent  bleeding,  until  the  child  is  born,  when  a  ligature  can  be 
placed  round  it. 

The  trunk  is  generally  expelled  by  the  pain  following  that  which 
expels  the  head.  As  a  rule,  it  is  sufficient  to  wait  quietly  for  the 
occurrence  of  the  pain.  In  normal  labour  there  is  no  danger  to  the 
child  at  this  stage,  even  if  the  body  is  not  expelled  for  several 
pains,  the  placental  circulation  being  still  intact.  Moreover,  if  not 
already  partially  asphyxiated,  the  child  is  generally  able  to  breathe 
at  this  stage,  if  it  requires  to  do  so.  If,  however,  the  child  has 
already  been  imperilled  by  prolonged  labour,  and  especially  after  a 
difficult  forceps  delivery,  it  may  be  sacrificed  by  prolonged  delay 
after  the  birth  of  the  head.  Increasing  lividity  of  the  face  shows 
the  child  to  be  alive.  But,  if  it  becomes  extreme,  and  especially  if 
it  is  accompanied  by  convulsive  twitchings,  it  is  an  indication  for 
accelerating  delivery.  The  uterus  may  then  be  stimulated  by 
friction,  the  woman  told  to  bear  down,  and  j)ressure  brought  to  bear 
on  the  breech  of  the  child  through  the  abdomen.  If  the  delay  is 
very  long,  and  the  sooner  if  the  child  appears  to  be  very  large  in 
proportion  to  the  genital  canal,  the  head  may  be  grasped  between 
the  hands,  avoiding  the  face,  and  gentle  traction,  not  enough  to 
endanger  the  spinal  cord,  may  be  made  upon  the  neck  during  a  pain. 
The  anterior  shoulder  should  be  delivered  first  from  under  the  pubes 
and  then  the  posterior  over  the  perineum.  If  there  is  still  difficulty 
in  delivering  the  shoulders,  then  as  soon  as  the  posterior  axilla  can 
be  reached  the  index  finger  may  be  hooked  into  it,  and  traction 
made  upon  it  in  addition  to  that  on  the  head,  care  being  taken  not 
to  use  force  enough  to  injure  the  brachial  nerves. 

After  tlie  shoulders  have  passed,  the  expulsion  of  tbe   body  of 

the  child  should  be  left  entirely  to  nature,  since,  if  the  uterus  be 

emptied  artificially,  it  is  more  likely  to  remain  flaccid,  and  permit 

haemorrhage.     In  all  cases  the  left  hand  should  be  placed  upon  the 

M.  20 


3o6  The   Practice  of   Midwifery. 

abdomen,  follow  down  the  fundus  as  it  diminishes  in  size,  and  make 
sure  that  it  remains  contracted.  This  is  an  important  measure  as 
a  safeguard  against  haemorrhage.  If  the  uterus  expels  the  child 
vigorously  it  is  likely  to  remain  contracted. 

If  the  child  breathes  and  cries  freely,  it  should  be  laid  near  the 
mother's  thighs,  in  such  a  position  that  it  does  not  hurt  her  by 
kicking  against  the  vulva.  If  the  presence  of  mucus  in  the  mouth 
is  shown  by  any  rattling  respirations,  it  should  be  wiped  out  with  a 
handkerchief. 

As  soon  as  the  head  appears,  the  eyes  and  their  neighbourhood 
should  be  wiped  clean  from  mucus  with  a  piece  of  absorbent  cotton 
soaked  in  a  saturated  solution  of  boracic  lotion  or  in  a  1  in  4,000 
perchloride  or  biniodide  of  mercury  solution.  If  any  purulent  or 
muco-purulent  discharge  has  been  noticed,  or  if  there  is  any 
reason  to  suspect  the  existence  of  gonorrhoea,  a  few  drops  of  a 
solution  of  perchloride  of  mercury,  1  in  2,000,  should  be  dropped 
into  the  eyes.  The  ophthalmia  neonatorum,  which  is  often  a  source 
of  permanent  blindness,  may  thus  be  averted.  A  solution  of  nitrate 
of  silver,  2  j)er  cent.,  may  also  be  used,  and  statistics  appear  to  show 
that  it  is  the  most  trustworthy  germicide  for  the  purpose ;  but  it 
has  the  drawback  that  it  is  apt  itself  to  set  up  a  slight  inflammation. 
To  avoid  this  the  use  of  sojDhol  5  per  cent.,  argyrol  25  to  50  per 
cent.,  protargol  10  to  20  per  cent,  solutions  has  been  suggested 
(see  Chap.  XLII.).  Other  microbes  than  the  gonococcus  may  set 
up  less  severe  forms  of  ophthalmia  neonatorum. 

Ligature  of  the  Funis. — It  was  formerly  recommended  to 
tie  the  funis  as  soon  as  the  child  cries  or  breathes  freely.  The 
experiments  of  Budin,^  however,  have  shown  that  the  opposite 
practice  is  desirable.  If  the  funis  is  left  untied,  circulation  in  the 
vein  generally  ceases  within  four  to  five  minutes,  and  the  pulsation 
in  the  arteries  within  eight  to  ten  minutes,  the  cessation  passing 
from  the  placental  end  towards  the  child.  If  the  funis  is  not  cut 
till  about  a  minute  after  pulsation  has  ceased,  there  is  hardly  any 
bleeding  from  the  placental  end.  If,  however,  it  is  tied  early,  a 
considerable  quantity  of  blood  escapes,  the  amount  of  which  was 
found  by  Budin  to  be  on  the  average  about  three  ounces  (88  gms.) 
greater  than  in  the  former  case.  It  may  be  inferred  that  this 
amount  of  blood  is  transferred  from  the  placenta  to  the  child  during 
the  few  minutes  after  birth,  partly  from  the  thoracic  aspiration 
during  inspiration,  partly  from  the  effect   of   the   pressure  of   the 

1  Budin,  "  A  quel  moment  doit-on  op^rer  la  ligature  du  cordon  ombilical  ?  "  Progres 
Medicalo,  1876. 


Management  of   Normal  Labour.  307 

uterus  on  the  placenta ;  and  that  it  serves  to  supply  the  extra 
amount  of  blood  required  to  fill  the  pulmonary  circulation  at  the 
time  when  the  lungs  take  the  place  of  the  placenta  as  organs  of 
respiration.  Hence  we  get  the  startling  result  that  to  tie  the  funis 
immediately  is  equivalent  to  bleeding  the  child  to  the  amount  of 
three  ounces  (90  gms.),  a  bleeding  which  would  correspond  to 
one  of  about  sixty  ounces  in  an  adult.  The  conclusions  arrived  at 
from  the  amount  of  blood  which  escapes  from  the  placenta  have 
been  confirmed  by  observations  on  the  increase  of  the  weight  of 
the  child  during  the  few  minutes  after  birth.  General  experience 
shows  that  the  children  are  more  vigorous  after  late  ligation  of  the 
funis,  suffer  less  loss  of  weight  in  the  few  dajys  after  delivery,  and 
more  quickly  begin  to  gain  weight  again.  Some  have  alleged  that 
they  are  more  liable  to  an  apparent  jaundice,  which  has  been 
thought  to  be  really  due  to  disintegration  of  over-abundant  blood- 
corpuscles.  The  observations  of  Schmidt,  however,  show  that 
exactly  the  opposite  is  the  case.-^ 

It  may  be  inferred  that  the  extra  amount  of  blood  is  an 
advantage  to  the  child,  especially  as  it  gains  very  little  nourish- 
ment from  its  mother  during  the  first  two  days.  If,  therefore, 
there  is  no  necessity  for  haste  on  account  of  the  condition  of  the 
mother,  or  in  order  to  resuscitate  an  asphyxiate  1  child,  the  funis 
should  not  be  tied  until  the  pulsations,  near  its  placental  end, 
have  stopped  for  a  minute  or  more,  or,  at  any  rate,  till  five 
minutes  have  elapsed  since  the  birth,  if  the  pulsations  continue 
longer.  In  the  majority  of  cases  the  pulsation  ceases  within  three 
or  four  minutes,  but  sometimes  it  continues  as  long  as  fifteen 
minutes  or  more.  Such  prolonged  pulsation  may  occasionally  be 
an  indication  of  adherent  placenta. 

The  material  commonly  prepared  by  the  nurse  for  tying  the  cord 
consists  of  several  strands  of  strong  thread,  tied  together  at  both 
ends,  but  a  narrow  tape  sterilised  by  boiling  or  by  immersion  in  an 
antiseptic  solution,  such  as  perchloride  of  mercury  1  in  1,000,  is 
preferable.  The  knot  should  be  tightened  gradually  and  firmly,  in 
order  to  compress  the  elastic  gelatinous  material  uf  the  cord, 
especially  in  cases  in  which  this  is  unusually  abundant,  otherwise 
bleeding  may  occur  after  an  interval.  When  the  funis  is  very  thick, 
it  should  always  be  looked  at  after  a  while  to  make  sure  that  the 
ligature  is  safe.  The  ligature  may  be  placed  as  close  to  the 
umbilicus  as  one  inch,  or  even  half  an  inch,  provided  that  there  is 
no  umbilical  hernia.     The  funis  is  then  cut  with  scissors  about  half 


'  Schmidt  Archiv  f.  (iyn.,  1894,  Vol.  XLV.,  lift.  2,  p.  28.3. 

20—2 


3o8  The  Practice  of   Midwifery. 

an  inch  beyond  the  ligature,  care  being  taken  that  no  injury  is  done 
to  the  limbs  of  the  infant.  It  is  quite  unnecessary  to  place  a  second 
ligature  on  the  placental  side  if  the  plan  has  been  adopted  of  waiting 
for  the  cessation  of  pulsation,  as  only  a  few  drops  of  blood  will 
escape.  The  oidy  case  in  which  the  second  ligature  ought  to  be 
used  is  that  in  which  the  hand  placed  on  the  uterus  finds  it  still  so 
large  that  it  may  have  within  it  a  twin  foetus.  The  object  in  this 
case  is  to  prevent  any  loss  of  blood  to  the  second  foetus,  in  case  there 
should  be  a  single  placenta  and  inosculation  of  the  foetal  vessels. 

The  methods  advocated  by  some  obstetricians  of  cauterising  the 
cut  end  of  the  cord  or  of  treating  the  cord  by  crushing  are  not 
necessary,  nor  indeed  are  they  practicable  in  ordinary  practice. 

Management  of  the  Third  Stage  of  Labour. — In  ordinary  cases 
of  labour,  a  correct  management  of  the  third  stage  is  the  most 
important  of  r.ll  the  duties  of  the  physician ;  and  it  is  at  this  stage 
that  erroneous  practice  is  still  most  frequent.  Only  a  few  years 
ago,  the  method  taught  in  most  text-books  was  to  wait  for  a  certain 
interval  after  delivery  for  contraction  of  the  uterus,  and  then  to  pass 
the  fingers  into  the  vagina  and  trace  up  the  cord,  feeling  for  its 
insertion  into  the  placenta.  If  the  insertion  could  be  felt,  the  cord 
was  to  be  wound  round  the  fingers  of  one  hand,  so  as  to  give  a 
purchase  for  pulling,  while  the  fingers  of  the  other  hand  in  the 
vagina  were  placed  on  the  cord,  so  as  to  direct  the  traction  at  first 
backward  in  the  axis  of  the  pelvic  inlet.  In  practice,  it  has  not 
been  uncommon  to  remove,  or  attempt  to  remove,  the  placenta  by 
traction  on  the  funis,  even  when  the  insertion  of  the  latter  could 
not  be  felt,  the  placenta  being  still  wholly  in  the  uterus.  The  objec- 
tion to  this  method  is,  that  any  traction  whatever  on  the  funis  pulls 
away  the  centi-e  of  the  placenta  from  the  uterine  wall,  and  so  creates 
a  vacuum  which  must  be  filled  up  either  by  blood  poured  out  from 
the  uterine  wall,  or,  less  frequently,  by  entrance  of  air  from  outside. 
Moreover,  by  drawing  down  the  placenta  like  an  inverted  umbrella, 
it  interferes  with  the  natural  mechanism  of  its  expulsion  (see  Figs. 
194,  195,  p.  286),  and  renders  its  bulk  greater  for  passing  through 
the  cervix  and  vagina.  Practitioners  who  adopt  the  correct  mode  of 
management  of  the  placenta,  and  are  unremitting  in  their  vigilance, 
are  almost  exempt  from  the  grave  accidents  of  j^ost-partuni 
haemorrhage,  and,  moreover,  save  their  patients  not  only  from 
the  inconvenience  of  after-pains,  excited  by  the  formation  and 
retention  of  clots  within  the  uterus,  but  also  from  the  grave 
dangers  of  septic  intoxication  or  septic  infection  so  Hkely  to  follow 
the  retention  of  any  portion  of  the  placenta  or  membranes  in  utero. 


Management  of    Normal  Labour.  309 

Expression  of  the  Placenta. — The  correct  mode  of  aiding  the 
delivery  of  the  placenta,  when  aid  is  required,  is  that  of  external 
pressure.  This  method  is  often  spoken  of  as  the  method  of 
Crede,  although  Cred6  only  revived  a  mode  of  treatment  previously 
known,  though  not  generally  practised.  During  the  birth  of  the 
body  of  the  child  the  physician  is  to  follow  down  with  his  hand  the 
contracting  uterus,  and  by  pressure,  and,  if  necessary,  gentle 
friction,  stimulate  it  to  maintain  its  retraction  after  the  child  is 
born.  After  the  birth  of  the  child,  if  the  fundus  uteri  can  be  felt 
as  a  firm  rounded  mass  it  is  left  alone.  If  it  appears  flaccid,  it  is 
gently  kneaded  until  firm  contraction  is  induced.  It  is  not  desirable, 
by  forcible  pressure,  to  attempt  to  completely  expel  the  placenta 
with  the  same  pain  which  expels  the  child,  or  immediately  after- 
wards. For  if  the  uterus  be  completely  emptied  before  thrombi 
have  had  time  to  form  in  the  vessels,  it  is  more  apt  to  relax  again 
quickly,  not  being  stimulated  by  the  presence  of  the  placenta 
within,  and  so  to  allow  haemorrhage  to  take  place. 

Provided  that  there  is  no  abnormal  haemorrhage,  the  physician 
at  short  intervals  places  his  hand  upon  the  uterus,  to  make  sure 
that  it  does  not  become  flaccid  and  dilate.  Kneading  the  uterus 
is  called  for  only  when  undue  relaxation  does  occur.  If  his 
attention  is  otherwise  occupied  for  any  considerable  time,  as  in 
resuscitating  a  child  born  asphyxiated,  he  directs  the  nurse  to 
keep  a  hand  on  the  uterus.  At  this  stage  it  is  best  for  the 
patient  to  lie  on  her  back.  Gravity  then  aids  the  descent  of  the 
placenta,  and  tends  to  counteract  any  collection  of  blood  within  the 
uterus.  The  position  is  also  most  convenient  for  expression  of  the 
placenta. 

Expression  of  the  placenta  may  be  carried  out  as  soon  as  there 
is  evidence  that  it  has  been  expelled  out  of  the  upper  contracting 
segment  of  the  uterus  into  the  dilated  cervix  and  vagina.  This  i? 
indicated  by  the  fact  that  the  fundus  is  noticed  to  rise  up  about 
an  inch  and  a  half  above  the  position  which  it  previously  occupied, 
while  it  becomes  reduced  in  circumference,  remaining  as  firm  or 
firmer  than  before,  and  the  distended  lower  uterine  segment  con- 
taining the  placenta  causes  a  distinct  bulging  above  the  pubes.  In 
the  majority  of  cases  this  occurs  within  twenty  minutes  to  half  an  hour 
after  the  birth  of  the  child.  An  additional  indication  may  be 
obtained,  if,  as  soon  as  the  child  is  born,  the  funis  is  drawn  down 
very  gently,  and  a  sterilised  thread  is  tied  round  it  where  it  passes 
over  t?ie  margin  of  the  vulva.  Descent  of  the  placenta  is  then 
indicated  by  a  further  descent  of  the  thread  externally.  As  soon  as 
evidence  of  the  descent  of  the  placenta  is  thus  obtained,  the  uterus 


3IO  The  Practice  of   Midwifery. 

should  be  grasped  by  one  or  both  hands,  the  fingers  being  placed 
behind  it  and  the  thumbs  in  front,  stimulated  by  pressure  and 
kneading  to  contract  if  flaccid,  and  then  at  the  height  of  the 
contraction  pressed  firmly  downward  in  the  axis  of  the  pelvic 
brim.  By  this  means  the  placenta  is  squeezed  out.  As  it 
passes  through  the  vulva  it  should  be  grasped  by  the  hand  and 
rotated,  so  as  to  twist  up  the  membranes  into  a  kind  of  cord,  which 
is  to  be  withdrawn  very  gradually,  so  as  to  avoid  its  tearing.  If  it 
is  felt  to  begin  to  tear,  it  should  be  seized  by  the  fingers  at  a  higher 
point  and  so  extracted. 

In  this  expression,  the  contractile  upper  segment  of  the  uterus 
acts  simply  as  a  piston,  by  means  of  which  the  pressure  of  the 
external  hand  is  transmitted  to  the  i)lacenta  lying  in  the  relaxed 
lower  segment  and  vagina.  It  is  necessary  for  it  to  be  contracted 
and  not  flaccid,  both  in  order  that  it  may  be  rigid  enough  to 
transmit  the  force,  and  to  avoid  the  risk  of  its  being  inverted  by 
the  external  pressure. 

If  there  is  no  descent  of  the  placenta  at  the  end  of  half  an  hour 
after  the  birth  of  the  child,  it  is  advisable  to  stimulate  the  uterus 
to  expel  it.  Uterine  contractions  will  be  *  recurring  by  this  time. 
These  are  to  be  stimulated  by  pressure  and  kneading  of  the  fundus. 
As  soon  as  an  active  contraction  is  called  forth  by  these  means,  so 
that  the  fundus  becomes  quite  hard  under  the  hand,  the  fundus  is 
grasped  by  both  hands,  and  concentric  compression  made  upon  it, 
at  the  same  time  that  it  is  pressed  downwards  in  the  direction  of 
its  axis.  The  size  of  the  uterine  body  is  felt  to  diminish  under 
the  hand  if  the  placenta  is  by  this  means  expelled  from  it.  Con- 
tinued downward  pressure  in  the  pelvic  axis  will  then  squeeze  the 
placenta  out  through  the  vulva. 

If  this  method  does  not  succeed  with  the  first  pain,  it  should  be 
repeated  with  successive  pains,  until  the  placenta  is  gradually 
detached.  An  unusual  delay  in  expulsion  may  mean  that  the 
placenta  is  more  adherent  than  usual  to  the  uterine  wall ;  but  the 
difiiculty  will  often  be  overcome  if  patience  be  exercised.  It  is 
advisable  to  wait  as  much  as  two  hours,  unless  there  is  undue 
haemorrhage,  before  introducing  the  hand  into  the  uterus  to 
se]3arate  the  placenta,  because  this  procedure,  even  with  careful 
antiseptic  precautions,  involves  some  degree  of  risk  of  carrying 
microbes  to  the  placental  site.  If,  however,  the  lower  margin  of 
the  placenta  can  be  felt  in  the  vagina  by  a  hand  carefully  sterilised, 
or  covered  by  a  sterilised  glove,  there  is  no  harm  in  seizing 
that  between  the  thumb  and  two  fingers,  and  aiding  the  pressure 
from  above,  during  the   uterine  contraction,  with  gentle  traction 


Management  of   Normal  Labour.  311 

upon  it,  care  being  taken  not  to  use  force  enough  to  tear  its  lacerable 
substance. 

If  rather  free  haemorrhage  occurs  from  the  vagina  with  the  early 
pains  of  the  third  stage,  more  active  stimulation  should  be  used 
by  pressure  and  gentle  kneading  of  the  fundus ;  and  the  expression 
of  the  placenta  should  be  commenced  earlier. 

Ahlfeld  recommends  the  expectant  plan  as  preferable  to  early 
expression  of  the  placenta  in  normal  cases.  No  pressure  or 
massage  is  to  be  applied  to  the  fundus.  After  delivery  and 
separation  of  the  child,  any  lacerations  which  bleed  are  to  be 
stitched.  Dry  sheets  are  to  be  placed  under  the  patient,  and  she 
is  to  be  well  covered  up  with  bed-clothes.  A  draw-sheet  is  placed, 
and  about  every  five  minutes  the  amount  of  blood  passing  is  noted, 
and  the  draw-sheet  shifted  to  a  dry  place.  The  pulse  is  also  to  be 
watched,  so  that  any  serious  intra-uterine  bleeding  would  be 
revealed  by  acceleration  of  the  pulse.  Only  after  an  interval  of 
from  one  and  a  half  to  two  hours,  unless  abnormal  haemorrhage 
occurs,  is  the  expression  of  the  placenta  to  be  commenced ;  the 
bladder  having  been  emptied  by  catheter  meanwhile.  The  advan- 
tages claimed  by  Ahlfeld  for  this  plan  are  that  the  average  amount 
of  blood  lost  is  less,  that  both  primary  and  secondary  post-jjcirtum 
haemorrhage  are  less  common,  and  that  artificial  extraction  is  rarely 
called  for.  It  is  obvious  that  this  method  favours  the  separation 
of  the  placenta  by  retro-placental  haematoma,  which  Ahlfeld  regards 
as  the  normal  mechanism ;  and  that  active  expulsion  of  the 
placenta,  with  a  minimum  effusion  of  blood,  would  more  rarely 
occur  when  it  is  employed.  The  long  waiting  required  will  render 
the  method  one  unlikely  to  be  adopted  as  a  general  rule. 

Examination  of  the  Placenta. — The  bag  of  membranes  will 
generally  have  become  inverted,  and  will  require  re-inversion  to 
bring  the  uterine  surface  outermost.  The  first  step  is  to  examine 
the  uterine  surface  of  the  placenta,  and  make  sure  that  it  is  com- 
plete, especially  along  the  margin,  and  that  no  part  is  left  behind 
in  the  uterus.  Any  adherent  clots  should  first  be  washed  away 
from  the  surface.  If  the  cotyledons  are  partially  separated,  the 
placenta  should  be  spread  out  flat,  or  with  the  uterine  surface  some- 
what concave,  and  then  it  will  be  possible  to  see  whether  the  parts 
all  fit  together,  and  none  is  missing.  In  this  examination,  any 
infarcts  or  hardened,  degenerated,  or  calcareous  patches  on  the 
surface  will  be  noted. 

The  next  step  is  to  see  that  the  whole  of  the  two  layers  of  mem- 
branes, amnion  and  chorion,  are   present.      They  are  most  easily 


312  The  Practice  of   Midwifery. 

separated  at  the  edges  if  placenta  and  membranes  are  placed  in  a 
basin  of  water.  The  chorion  is  outermost  and  continuous  with 
the  edge  of  the  placenta.  The  amnion  can  be  stripped  up  to  the 
insertion  oi  the  funis.  The  experienced  accoucheur  will  judge  at 
a  glance  that  none  of  the  chorion  is  deficient,  by  the  whole  of  the 
membranes  having  a  rough  outer  surface,  due  to  the  portion 
of  decidua  remaining  attached  to  the  chorion.  The  amnion  is 
smooth  on  both  sides,  thinner  but  stronger  than  the  chorion. 
There  should  be  sufficient  membranes  present  to  have  enclosed 
the  foetus,  allowance  being  made  for  the  shrinking  due  to  their 
elasticity.  Except  in  the  case  of  placenta  prsevia,  where  the 
membranes  have  been  ruptured  at  the  edge  of  the  placenta,  there 
should  be  a  border  of  them  all  round,  but  deeper  at  one  part  than 
another. 

It  is  to  be  noted  that  the  chorion  is  more  likely  than  the  amnion 
to  be  left  behind  in  the  uterus,  wholly  or  partially.  The  amnion 
is  not  likely  to  be  left  behind  when  the  chorion  comes  away ;  but  it 
may  be  torn  away  from  the  edge  of  the  placenta  and  separated  from 
the  chorion,  when  it  has  been  carried  down  as  a  caul,  or  as  a  bag 
descending  far  in  advance  of  the  head.  When  the  amnion  has  been 
torn  away,  special  care  is  necessary  to  make  sure  that  none  of  the 
chorion  has  been  left  behind. 

If  a  placenta  succenturiata  had  been  left  behind  in  the  uterus, 
the  fact  would  be  revealed  by  a  corresponding  deficiency  in  the 
chorion,  and  by  the  torn  ends  of  the  vessels  which  supj)lied  it, 
passing  from  the  edge  of  the  main  placenta,  or  separately  from  a 
velamentous  insertion  of  the  funis. 

If  any  portion  of  the  placenta  or  any  large  portion  of  the  chorion 
appears  to  be  absent,  the  hand  covered  with  a  sterilised  rubber 
glove  must  be  introduced  into  the  uterus,  and  it  must  be  found 
and  removed  at  once.  Small  pieces  of  the  chorion  may  be  left  to 
come  away  by  themselves.  In  such  case,  if  any  offensive  dis- 
charge occurs,  or  febrile  symptoms  arise,  the  uterus  must  be  at 
once  explored. 

Examination  of  the  Perineum. — After  the  delivery  of  the 
placenta  a  careful  examination  should  be  made  as  to  whether  there 
is  any  laceration  of  perineum,  so  that  any  rent  may  be  immediately 
sewn  up.  Visual  examination  is  better  than  digital ;  and,  if  there 
is  any  doubt,  a  good  light  must  be  obtained  for  the  inspection. 
Many  lacerations  remain  unobserved  for  want  of  a  visual 
examination.  The  mode  of  treating  any  laceration  will  be  here- 
after described. 


Management  of   Normal  Labour.  313 

Use  of  the  Binder.— The  object  of  the  binder  is  not  to  serve 
as  a  prophylactic  against  haemorrhage,  for  which  purpose  it  is 
worse  than  useless,  but  simply  to  supply  that  support  to  the 
abdominal  viscera  which  is  taken  away  by  the  sudden  diminution 
of  tension.  The  binder  should  never  be  applied  until  at  least 
half  an  hour  has  elapsed  since  the  birth  of  the  child,  and  a 
sufficient  continuous  contraction  of  the  uterus  has  been  secured. 
Up  to  that  time  the  physician  should  keep  his  hand  on  the 
uterus,  observing  its  conditions,  kneading  it  if  it  becomes  large 
and  soft,  or  haemorrhage  occurs,  but  remembering  that  a  certain 
alteration  of  hardness  and  softness  is  the  physiological  law.  If 
there  is  any  excess  of  sanguineous  discharge,  or  if  the  contraction 
of  the  uterus  is  unsatisfactory,  he  must  continue  this  observation 
for  a  longer  time,  until  he  is  certain  that  there  is  no  longer  risk 
of  haemorrhage.  The  pulse  at  this  time  will  generally  have  fallen 
down  to,  or  even  below,  its  normal  level,  and  an  unusually  rapid 
pulse,  such  as  one  of  100  or  more  per  minute,  unless  accounted 
for  by  the  severity  of  the  labour,  or  other  known  cause,  must  be 
taken  as  indicating  a  risk  of  haemorrhage.  As  a  greater  security 
against  haemorrhage,  it  is  recommended  by  some  to  give  after 
delivery  of  the  placenta,  as  a  routine  practice,  a  dose  of  ergot, 
about  a  drachm  of  the  liquid  extract,  or  the  liquor  secalis 
ammoniatus.  In  the  case  of  a  strong  healthy  woman,  whose 
uterus  has  been  acting  vigorously,  this  seems  unnecessary,  but  it 
should  always  be  given  to  a  weakly  patient,  or  when  there  has 
been  any  indication  of  uterine  inertia  or  tendency  to  haemorrhage. 
Its  use  in  such  cases,  by  preventing  the  formation  of  clots,  tends 
to  avert  after-pains,  as  well  as  haemorrhage.  According  to 
Herman's  ^  observations,  the  use  of  the  binder  makes  no  difference 
as  regards  the  subsequent  size  of  the  abdomen.  But  if  a  lady, 
in  future  years,  is  not  quite  satisfied  with  her  figure,  she  will  be 
apt  to  lay  the  blame  on  an  accoucheur  who  omitted  the  use  of  the 
binder.  It  is  possible  that  its  use  is  in  reality  some  safeguard 
against  persistent  flaccidity  of  the  abdominal  wall  and  consequent 
pendulous  abdomen. 

In  applying  the  binder  the  soiled  linen  and  napkins  should  first 
be  removed,  and  the  draw-sheet  shifted,  the  patient  being  disturbed 
as  little  as  possible.  The  binder  should  be  wide  enough  to  reach 
from  the  ensiforrn  cartilage  to  the  pubes,  and  long  enough  to  over- 
lap across  the  abdomen  only.  One  end  is  rolled  up  to  pass  it 
beneath  the  patient,  and  care  must  be  taken  that  it  is  spread  out 

'  lleruian,  TrariH.  Obst.  Soc.  London,  1890,  Vol.  XXXU.,  p.  108. 


314  "    The  Practice  of   Midwifery. 

evenly,  and  low  enough  down  over  the  hips.  The  nearer  end  is 
then  laid  over  the  abdomen,  and  held  at  its  lower  margin  with  the 
left  hand,  while  the  right  hand  draws  the  further  end  smoothly 
over  it.  The  two  layers  are  then  held  together,  at  the  desired 
tension,  by  the  left  hand,  while  the  right  hand  fixes  them  with 
large  safety-pins  going  from  below  upward.  The  first  pin  is 
placed  close  to  the  lower  margin  of  the  binder,  which  should  pass 
below  the  level  of  the  great  trochanter  ;  the  second  a  little  below 
the  level  of  the  crest  of  the  ilium  ;  the  third  above  the  level  of 
the  crest  of  the  ilium.  These  three  pins  are  sufficient,  but  a 
fourth  may  be  placed  higher  up.  It  is  a  good  plan  to  place  a 
folded  towel  under  the  line  of  pins,  not  as  a  pad,  but  to  make  it 
easier  to  avoid  pricking  the  skin  in  inserting  the  pins.  A  thin 
layer  of  cotton  wool  wrapped  in  gauze  or  muslin  may  be  used  for 
the  same  object.  A  pad  is  sometimes  placed  underneath  the 
binder,  with  the  idea  of  compressing  the  fundus.  This  generally 
pushes  the  fundus  on  one  side,  and  it  is  very  doubtful  whether 
it  is  of  any  use  in  maintaining  contraction.  If  any  pad  at  all  is 
used,  the  best  is  a  small  saucer,  wrapped  in  a  napkin,  and  placed 
with  its  concave  surface  over  the  fundus,  so  that  it  does  not  get 
displaced. 

After  the  application  of  the  binder  the  mother  should  be  left 
perfectly  quiet  to  rest,  and,  if  possible,  to  sleep.  An  opiate  is  not 
necessary,  as  a  general  rule,  but  some  light  nourishment,  such 
as  an  egg  beaten  up  with  hot  milk,  or  beef  tea,  may  be  given  with 
advantage. 

Use  of  Anaesthetics  in  Labour. — In  the  great  majority  of 
cases  of  labour  where  an  anaesthetic  is  required  chloroform  is  the 
one  to  be  chosen.  Even  when  it  is  necessary  to  give  it  to  the  full 
surgical  extent,  as  in  obstetric  operations,  it  does  not  appear  to 
involve  the  same  increased  risk,  as  compared  with  other  ansesthetics, 
such  as  ether,  which  it  does  in  ordinary  cases.  The  explanation  of 
this  is  probably  to  be  found  in  the  physiological  hypertrophy  of  the 
heart  which  occurs  during  pregnancy,  in  the  stimulation  of  heart 
and  lungs  which  occurs  during  each  labour  pain,  even  when  the 
patient  is  pretty  deeply  angesthetised,  and  perhaps  also  to  some 
extent  in  the  high  abdominal  pressure  due  to  tlie  presence  of  the 
pregnant  uterus.  All  these  causes  diminish  the  risk  of  sudden 
anaemia  of  the  brain.  If  vomiting  occurs,  and  food  is  present  in 
the  stomach,  it  is  of  course  necessary,  whatever  be  the  anaesthetic 
used,  to  see  that  the  patient  does  not  get  suffocated  through  the 
vomited  matter  obstructing  the  larynx.       If  given   to  the  partial 


Manag'ement  of   Normal  Labour.  315 

extent  which  alone  is  ever  necessary  in  normal  labour,  chloroform 
may  be  regarded  as  entirely  free  from  risk.  Ether  is  more  dis- 
agreeable to  the  patient  than  chloroform,  and  has  not  the  same 
satisfactory  effect  of  deadening  pain  when  given  in  partial  degree. 
Most  of  the  objections  formerly  made  to  the  use  of  chloroform  in 
normal  labour  have  not  now  to  be  considered  ;  and,  as  a  rule,  it 
may  always  be  given  whenever  the  pains  are  felt  acutely,  or  the 
patient  is  desirous  to  take  it.  Its  use  is  a  distinct  advantage, 
putting  aside  the  question  of  relief  of  pain,  in  those  cases  in  which 
the  pains  are  too  violent,  or  occur  at  too  short  intervals.  There 
are,  however,  two  drawbacks  to  its  use  :  first,  that  it  tends  to 
diminish  the  vigour  of  the  pains,  and  so  is  apt  somewhat  to  increase 
the  duration  of  labour  ;  secondly,  that  it  increases  the  risk  of  j^ost- 
partwn  hsemorrbage  in  patients  predisposed  to  that  accident.  These 
disadvantages  may  be  avoided  to  a  great  extent  by  not  giving  the 
chloroform  too  freely.  When,  however,  there  is  manifest  inertia 
of  the  uterus  or  a  history  of  post-partum  haemorrhage  on  former 
occasions,  it  is  better  to  avoid  it  entirely,  or  give  it  only  in  infini- 
tesimal degree.  Thus,  when  a  patient  is  very  anxious  to  take 
chloroform,  and  its  effect  appears  undesirable,  a  very  little 
chloroform  may  be  mixed  with  eau-de-Cologne. 

Anodynes  in  the  First  Stage  of  Labour. — As  a  rule  chloroform 
should  not  be  given  until  the  pains  of  the  expulsive  stage  begin. 
If  the  pains  of  the  first  stage  are  very  distressing  to  the  patient, 
and  especially  if  at  the  same  time  the  os  is  rigid  and  slow  in 
yielding,  either  chloral  or  some  preparation  of  opium,  such  as 
Battley's  liquor  opii  sedativus,  may  be  given.  The  effect  is  often 
not  only  to  diminish  pain,  but  to  lessen  spasmodic  rigidity  of  the 
OS,  and  allow  the  patient  to  recruit  her  strength  by  some  sleep  in 
the  intervals  of  the  pains.  Chloral  is  generally  preferable  to 
opium.  Two  doses  of  fifteen  grains  may  be  given  with  from  half 
an  hour  to  an  hour's  interval,  and  the  dose  repeated,  if  necessary, 
after  one  or  two  hours.  If  there  is  sickness,  and  the  medicine 
cannot  be  retained,  a  moderate  hypodermic  injection  of  acetate  of 
morphia  (a  sixth  or  a  quarter  of  a  grain)  may  be  administered. 
In  some  cases,  however,  of  muscular  rigidity  of  the  os,  especially 
when  the  uterus  is  active,  and  the  membranes  have  ruptured  pre- 
maturely, chloroform  is  found  to  be  far  more  efficacious  than  chloral, 
and  in  such  instances  it  may  be  desirable  to  give  it,  even  in  the 
first  stage  of  lal)our. 

Chloroform  in  the  Second  Stage. — The  chloroform  is  to  be  given  in 
such  a  way  as  only  to  dull  sensibility,  and  not  to  produce  com- 
plete anaesthesia,  or  entirely  abolish  self-control.     For  this  purpose 


3i6  The  Practice  of   Midwifery. 

it  may  be  sufficient  to  place  the  inhaler  over  the  face  only  during 
the  pains,  allowing  the  patient  to  come  round  in  the  intervals. 
The  chloroform  may  be  dropped  on  any  simple  form  of  inhaler 
(such  as  Skinner's),  or  on  some  absorbent  cotton  wool  placed  at  the 
bottom  of  a  tumbler.  If  more  convenient,  the  patient  may  be 
allowed  to  hold  the  inhaler  herself,  provided  the  physician  makes 
sure  that  she  is  actively  holding  it,  not  allowing  it  to  rest  passively 
over  or  near  the  face.  Junker's  inhaler  is  a  very  good  one  for 
administering  the  chloroform.  The  patient  may  herself  hold  the 
mouthpiece,  while  the  physician  with  his  left  hand  works  the 
bellows,  without  having  to  lean  over  the  patient,  and  has  his  right 
hand  free.  This  inhaler  economises  greatly  the  quantity  of  chloro- 
form used,  and  is  safer  than  any  other  for  the  administration  of 
chloroform  to  the  surgical  degree.  As  the  chloroform  is  given 
more  gradually  with  this  inhaler,  it  must  be  continued  to  some 
extent  during  the  intervals,  as  well  as  during  the  pains,  sufficiently 
to  render  the  patient  somnolent  in  the  intervals,  and  only  partially 
conscious  during  the  pains.  Just  as  the  head  is  about  to  pass  the 
vulva,  if  the  pains  come  on  with  increased  vigour  the  administra- 
tion may  be  pushed  more  nearly  to  the  point  of  complete 
anaesthesia. 

"When  anaesthesia  to  the  surgical  degree  is  required,  as  for 
obstetric  o]3erations,  it  is  desirable  to  have  another  person  for 
administering  the  anaesthetic,  who  may  give  his  whole  attention 
to  that  duty.  It  is  frequently  convenient  to  be  able  to  apply 
forceps  without  the  necessity  for  having  an  assistant.  In  such 
case,  if  chloroform,  be  given,  it  should  only  be  to  a  degree  short 
of  abolishing  the  patient's  self-control,  otherwise  the  partial 
anaesthesia  renders  the  operation  much  more  difficult.  As  an 
anaesthetic  for  obstetric  operations  chloroform  has  the  advantage 
over  ether  that  it  more  completely  relaxes  the  uterus,  when  given 
to  the  full  extent.  This  is  especially  of  advantage  in  the  opera- 
tion of  version.  Ether,  however,  is  to  be  preferred,  if  an  anaesthetic 
is  indispensable,  in  cases  in  which  the  patient  is  greatly  exhausted 
and  the  pulse  feeble,  as,  for  instance,  after  severe  ante-partum 
haemorrhage. 

In  the  third  stage  the  administration  of  chloroform  involves  a 
risk  of  relaxation  of  the  uterus  and  consequent  haemorrhage.  It 
should  not  therefore  be  given  at  this  stage,  unless  it  is  required 
for  the  removal  of  an  adherent  placenta. 

Spinal  ancesthesia. — The  plan  of  inducing  anaesthesia  by  injection 
of  a  solution  of  an  analgesic  into  the  subarachnoid  space  has  been 
practised   in  a  considerable  number  of  surgical  operations,  more 


Management  of   Normal  Labour.  317 

especially  on  the  Continent  and  in  America.  The  same  method 
has  been  extended  to  the  production  of  analgesia  in  normal  labour, 
and  in  the  performance  of  obstetric  operations. 

The  injection  is  made,  with  strict  antiseptic  precautions,  between 
the  laminse  of  the  twelfth  dorsal  and  first  lumbar  or  of  the  fourth 
and  fifth  lumbar  vertebrse.  The  needle  should  be  four  inches  lone, 
and  is  best  made  of  platinum,  with  an  iridium  point.  It  is  inserted 
immediately  above  the  spinous  process  of  the  first  lumbar  or 
1  centimetre  below  and  outside  the  spinous  process  of  the  fourth 
lumbar  vertebra,  the  patient  being  placed,  if  possible,  in  the  sitting 
posture,  with  the  back  well  arched  forwards.  It  is  directed 
vertically  downwards  and  slightly  inwards,  and  will  enter  the 
interval  between  the  laminae  of  the  twelfth  dorsal  and  first  lumbar 
or  of  the  fourth  and  fifth  lumbar  vertebrae,  and  penetrate  the  sub- 
arachnoid space,  as  is  shown  by  the  escape  of  clear  cerebro-spinal 
fluid  through  the  needle. 

A  few  drops  of  cerebro-spinal  fluid  are  first  withdrawn,  and  then 
the  syringe  is  attached  to  the  needle,  and  1  cc.  of  a  solution  of 
tropacocaine  5  to  8  per  cent.,  1  cc.  of  a  5  per  cent,  solution  of 
stovaine  with  a  5  per  cent,  solution  of  glucose,  or  1  cc.  of  a  solution 
containing  10  eg.  of  stovaine  and  1  mg.  of  neutral  strychnine 
sulphate  very  slowly  injected. 

The  needle  is  now  withdrawn  and  the  puncture  sealed  by 
collodion.  The  analgesia  commences  almost  immediately  and  is 
usually  complete  in  from  five  to  ten  minutes.  The  drawbacks  to 
the  method  are  that  the  duration  of  the  analgesia  is  uncertain  and 
comparatively  short,  varying  from  thirty  minutes  up  to  three 
hours  or  more,  but  being  on  the  average  a  little  over  an  hour. 
The  injections  may  be  repeated  ;  but  in  some  cases  in  which  f  grain 
of  cocaine  has  been  used,  alarming  symptoms  of  cardiac  and  general 
collapse  have  occurred. 

Lindenstern  records  500  cases.  In  13  the  method  failed,  in  seven 
there  was  marked  collapse,  in  34  vomiting  occurred  during  the 
operation  and  in  54  after  the  operation,  and  in  100  of  the  cases 
more  or  less  severe  headache  followed.  The  latter  appears  to 
depend  upon  a  febrile  reaction,  since  a  second  puncture,  made 
in  cases  of  severe  headache,  has  shown  the  cerebro-spinal  fluid  to 
be  turbid,  and  to  contain  many  polynuclear  leucocytes. 

If  cocaine  is  used  it  appears  in  a  considerable  proportion  of  cases 
to  stimulate  uterine  contraction.  The  method  is  therefore  not 
suitable  when  it  is  desired  to  relax  the  uterus  for  the  performance 
of  an  obstetric  operation,  such  as  turning.  On  the  other  hand, 
artificial  delivery  has  often  l)een  found  necessary  after  the  injection, 


3i8  The  Practice  of   Midwifery. 

and  this  is  attributed  to  the  paralysis  of  the  abdominal  muscles 
produced  by  the  analgesia. 

It  thus  appears  that  the  inconveniences  of  the  method  exceed 
in  general  those  of  chloroform,  and  it  is  obvious  that  any  failure 
of  perfect  antisepsis  would  involve  a  serious  risk.  Hahn  ^  collected 
eight  deaths  in  1,708  recorded  cases,  in  some  of  which  lesion  of 
the  cerebral  or  spinal  meninges  were  found  at  the  necro^Dsy.  Since 
then  5,350  cases  have  been  recorded  with  five  deaths.  Hardruin^ 
mentions  fifteen  cases  of  death  from  spinal  anaesthesia  as  coming 
under  his  observation,  and  a  large  number  of  cases  in  which 
serious  complications  occurred.  On  the  other  hand,  Jonnesco  has 
recorded  recently  1,015  cases  of  spinal  analgesia  without  a  death, 
and  in  623  of  these  cases  he  has  used  stovaine  and  strychnine, 
and  maintains  that  this  combination  prevents  all  the  dangers  which 
may  follow  the  use  of  stovaine  alone.  He  considers  spinal  analgesia 
absolutely  safe,  and  free  from  all  drawbacks  and  dangers. 

Scopolamine  Morphine  Narcosis. — This  method  has  been 
strongly  advocated  by  von  Kronig.^  He  injects  during  labour  200 
to  6^5  grain  scopolamine  with  J  grain  morphine  and  repeats  the 
scopolamine  at  intervals  depending  upon  the  result  obtained.  In 
successful  cases  the  patient  passes  into  a  condition  of  "  Dammer- 
schlaf "  or  twilight  sleep,  and  after  a  successful  sleep  of  this  kind 
the  patient  awakes  quite  happy  and  declaring  that  she  has  felt 
nothing.  The  dosage  is  determined  by  the  test  of  the  patient's 
consciousness.  It  is  sufficient  if  the  interruption  of  her  mental 
associations  is  so  complete  that  sensation  disappears  with  sufficient 
rapidity  from  the  memory.  According  to  von  Kronig  the  duration 
of  the  labour  is  not  increased,  the  risk  to  the  mother  is  practically 
7iil,  and  there  is  no  evidence  of  any  increased  risk  to  the  children. 
A.  Bertins^  from  an  experience  of  400  cases  urges  caution  in  the 
use  of  this  method.  In  36  per  cent,  of  the  cases  no  analgesia 
resulted,  while  in  38  cases  the  regularity  of  the  uterine  contractions 
was  lessened,  leading  to  delay  or  suspension  of  the  j)ains,  and  to 
the  death  of  the  foetus  through  prolonged  labour  and  weakening  of 
muscular  power.     No  doubt  in  cases  where  the  patient  can  be  kept 

1  Hahn,  "  Ueber  subarachnoideale  Cocaininjectionen  nach  Bier,"  Centralbl.  f.  d. 
Grenzgebiete  der  Med.  u.  Chir.,  1901,  IV.  304—317  and  340—354. 

2  A.  E.  Barker,  Brit.  Med.  Journ.,  1908,  Vol.  II.  ;  Lindenstern,  Beitrag  z.  Klin. 
Chir.  Tubingen,  January,  1908  ;  P.  Hardruin,  Archiv  gen.  de  Chinargie,  August,  1908  ; 
Therapeutic  Gazette,  August,  1907  ;  Jonnesco,  Brit.  Med.  Journ.,  November  13,  1909, 
p.  1396. 

8  Von  Kronig,  Deutsch.  Med.  Wochsch.,  June,  1908. 

^  A.  Bertins,  Journ.  Americ.  Med.  Assoc.  January  11,  1908. 


Manag-ement  of   Normal  Labour.  319 

under   skilled  observation  the  method  may  be  of  value,  but  it  is 
hardly  suited  for  ordinary  practice. 

Maternal  Mortality  in  Childbirth. — Statistics  relating  to  this 
subject  are  in  this  country  extremely  scanty,  and  it  is  difficult  to 
arrive  at  any  exact  conclusions.  From  hospital  statistics  Matthews 
Duncan^  estimated  the  death-rate  as  about  1  in  120.  Among  the 
105,749  confinements  of  married  women  occurring  during  the  three 
years  1894 — 1896  in  New  South  Wales  there  were  714  deaths,  or  a 
death-rate  of  1  in  148.  From  the  data  collected  by  Coghlan  in 
connection  with  these  figures  it  appears  that  the  risk  to  the  mother 
is  greater  at  the  first  birth  than  at  any  subsequent  one  up  to  the 
ninth,  the  minimum  risk  being  met  with  at  the  fourth.  The  risk 
attendant  on  a  first  birth  is  at  a  minimum  at  the  ages  of  twenty- 
two  or  twenty-three  years,  when  it  is  0"0068.  as  compared  with 
0*028  at  the  age  of  thirty-nine. 

The  risk  for  unmarried  women  in  childbirth  is  greater  at  every 
age  than  in  the  married,  the  disproportion  in  the  risk  being 
greatest  at  the  lower  ages.  In  Saxony  during  the  years  1883 — 1890 
for  every  10,000  children  born  there  died  66*6  mothers,  or  a 
mortality  rate  of  1  in  166. 

During  the  ten  years  1894 — 1903  in  the  Rotunda  Hospital, 
Dublin,  of  15,205  labours  in  the  intern  maternity  department 
56  mothers  died,  or  0*36  per  cent.^  During  the  same  time  of 
14,818  cases  in  the  extern  department  38  mothers  died,  or  0*25  per 
cent. ;  a  total  death-rate  of  94,  or  0*27  per  cent.,  in  30,023  confine- 
ments. In  the  same  ten  years  in  England  and  Ireland  of 
10,290,289  confinements  there  died  50,877  women,  or  a  death-rate 
of  0'49  per  cent. 

Fcetal  Mortality. — Of  2,060,657  children  born  in  Germany 
during  the  year  1900,  64,518  in  all,  including  premature  births, 
were  born  dead,  or  3*1  per  cent.  In  the  ten  years  1893  to  1902 
in  Hamburg  there  were  registered  236,050  births.  Of  these  223,390 
were  vertex  presentations  with  a  death-rate  of  2  per  cent. ;  885  face 
presentations  with  a  death-rate  of  13  per  cent. ;  7,066  breech 
presentations  with  a  death-rate  of  22  per  cent. ;  and  1,640  trans- 
verse presentations  with  a  death-rate  of  38*9  per  cent.     The  foetal 

1  Matthews  Duncan,  On  the  Mortality  of  Childbed  and  Maternity  Hospitals,  Edin., 
1870;  Schultze,  von  Winckel,  Handbuch  der  Geburtshtilfe,  Vol.  II.,  Part  3,  s.  1683  ; 
Still  Births  in  England  and  other  Countries,  Government  Return,  1893  ;  Report  on 
the  Decline  of  the  liirth  Rate  and  Mortality  of  Infants  in  New  South  Wales,  Sydney, 
1904. 

2  Jellett,  Manual  oi  Midwifery,  19U5,  p.  297. 


320  The   Practice  of   Midwifery. 

death-rate  in  lying-in  hospitals,  owing  to  the  large  percentage  of 
primiparae,  and  the  number  of  complicated  cases  admitted,  is  con- 
siderably above  that  for  the  country  as  a  whole  ;  thus  in  the  Charite 
Hospital,  Berlin,  between  1884  and  1901  the  foetal  death-rate  was 
6*5  per  cent. 

In  10,803  births  at  the  Kotunda  Hospital  605  infants  were 
born  dead,  or  1  in  17*8  =  5*8  per  cent.,  while  248  died  in  the 
hospital,  making  a  total  number  born  dead  or  dying  in  hospital  of 
853,-1  in  12-5  =  8  per  cent. 

There  is  a  higher  percentage  mortality  among  boys  than  girls, 
and  the  death-rate  of  illegitimate  is  higher  than  tbat  of  legitimate 
children. 

The  proportion  of  children  dying  during  birth  to  those  dying 
during  pregnancy  is  difficult  to  estimate,  but  in  the  three  years 
1899—1901,  of  121,183,  or  3*15  per  cent.,  children  born  dead  in 
Prussia,  2*6  per  cent,  died  during  birth,  and  0"5  per  cent,  were 
dead  before  labour  set  in. 


Chapter   XIV. 
FACE    PRESENTATIONS. 


Although  labour  with  face  presentation  cannot  be  regarded  as 
normal,  yet,  in  the  great  majority  of  cases,  it  is  completed  naturally. 
The  mechanism  of  labour  in  face  presentation  has  great  analogy  to 


Fig.  199. — Presentation  of  the  face  at  the  pelvic  brim  in  a  position 
intermediate  between  second  and  third. 

that  in  the  vertex  presentation,  and  should  therefore  be  considered 
in  close  relation  with  it. 

In  face  presentation,  the  head,  instead  of  being  flexed  upon  the 
sternum,  is  extended,  so  that  the  occiput  is  reflected  upon  the  back, 
and  the  face  and  forehead  form  the  presenting  part  (see  Fig.  199). 
The  consequence  is  that  the  chest  is  thrown  forward  against  the 
uterine  wall,  and  the  back  is  separated  from  it.  In  face  presenta- 
tion, the  action  of  the  lever  formed  by  the  diameter  of  the  head 
which  is  thrown  across  the  pelvis  (see  p.  247),  acted  on  by  the 
resistance  at  its  two  extremities,  is  reversed.  The  fulcrum  of  the 
lever  is  now  formed  by  the  point  C  (Fig.  201),  where  the  line  of 
force,  acting  through  the  condyles,  cuts  the  fronto-mental  diameter, 

M.  21 


322 


The   Practice  of   Midwifery. 


F  M.  This  fulcrum  is  now  nearer,  not  to  the  posterior,  but  to  the 
anterior  end  of  the  lever  (compare  Fig.  201  with  Fig.  155,  p.  247). 
The  posterior  arm  of  the  lever  is  therefore  the  longest,  and  has  the 
mechanical  advantage.  The  head  therefore,  instead  of  tending  to 
become  flexed,  becomes  more  and  more  extended,  until  the  chin 
becomes  the  most  advanced  point. 

It  follows  that  there  must  be  some  intermediate  position  of 
partial  extension  in  which  the  two  arms  of  the  lever  are  equal,  and 
their  action  balanced.  From  this  position,  if  ever  so  little  flexion 
occurs,  the  anterior  arm  of  the  lever  gets  the  advantage,  flexion 


Fig.  200. — Diagram  of  the  head  completely  extended  entering  the  pelvic  inlet 
with  its  vertico-mental  diameter  corresnonding  to  the  axis  of  the  pelvis. 
(After  Kaltenbach,  Zeitsch.  f.  Geburts.  n.  Gyn.,  Vol.  XXI.) 


progresses,  and  ordinary  vertex  presentation  results  ;  if  ever  so 
little  further  extension  occurs,  the  posterior  arm  of  the  lever  gets 
the  advantage,  extension  goes  on,  and  face  presentation  is  produced. 
This  immediate  position  is  called  broiv  presentation,  the  prominence 
of  the  forehead  being  the  presenting  point,  and  the  anterior 
fontanelle  and  the  root  of  the  nose  within  reach  at  about  equal  dis- 
tances in  opposite  directions.  As  it  is  thus  a  position  of  unstable 
equilibrium,  the  head  could  never  pass  through  the  pelvis  in  brow 
presentation,  even  if  there  were  room  for  it  so  to  pass.  Generally 
there  is  not  room,  the  vertico-mental,  or  longest  diameter  of  the 
head,  being  thrown  across  the  pelvis.  The  head  may,  however,  be 
arrested  in  a  position  of  a  brow  j)resentation,  though  even  this  is 
very  rare ;  and  when  this  haj)pens,  there  is  considerable  difficulty 


Face   Presentations. 


323 


in  effecting  delivery.  As  a  general  rule,  brow  presentations  are 
converted,  not  into  vertex,  but  into  face  presentations.  For  there 
must  have  been  some  cause  leading  to  the  partial  extension,  and 
this  will  generally  go  on  to  j)roduce  complete  extension,  the  head- 
lever  no  longer  tending  to  counteract  it.  It  is  thus  evident  that  all 
cases  of  face  presentation,  except  those  existing  during  pregnancy, 
must  have  passed  through  the  stage  of  brow  presentation,  in  their 
deviation  from  the  normal  condition. 

The  rarer  variety  of  primary  face  presentations  in  which  the 
extension  of  the  head  is  undoubtedly  present 
before  the  onset  of  labour,  as,  for  example,  in 
a  case  of  congenital  enlargement  of  the  thyroid 
gland,  must  be  distinguished  from  secondary, 
in  which  the  extension  of  the  head  occurs  after 
the  commencement  of  labour. 


Frequency   of    Face    Presentation. — The 

frequency  of  face  presentation  is  variously 
estimated  by  different  authors.  The  statistics 
of  the  Guy's  Hospital  Lying-in  Charity  (out  of 
49,145  cases)  give  "33  per  cent.,  or  1  in  303 ; 
Churchill  (out  of  nearly  250,000  cases  collected) 
gives  the  frequency  as  1  in  231 ;  Collins,  for 
the  Piotunda  at  Dublin,  as  only  1  in  497 ; 
Pinard,  for  the  Maternite  at  Paris  (out  of 
81,711  cases),  as  1  in  225 ;  Spiegelberg,  from 
German  statistics,  as  1  in  324.  It  appears, 
therefore,  that  no  uniform  difference  is  pro- 
duced by  the  dorsal  position  in  labour  generally 
adopted  on  the  Continent. 


Fig.  201. — Diagram  of 
head-lever  in  face 
presentation. 

A  C,  axis  of  expul- 
sive force  passing 
through  condyles. 

F  M,  frontal-men- 
tal diameter  of  head. 

C,  fulcrum  of  lever. 


Causation. — One  of  the  causes  which  may  tend  to  produce  face 
presentation  is  the  peculiar  shape  of  the  child's  head,  namely,  what 
is  called  the  dolicho-cephalic  shape,  in  which  the  occiput  projects 
more  than  usual,  and  the  posterior  arm  of  the  head-lever  is  there- 
fore not  so  much  as  usual  exceeded  in  length  by  the  anterior  in  its 
normal  position  (see  Fig.  155,  p.  247).  There  is  no  doubt  that  this 
cause  will  tend  to  facilitate  face  presentations,  if  it  exists,  but  it  is  not 
positively  decided  whether  it  is,  in  point  of  fact,  a  cause  commonly 
in  operation.  Budin,'-  measuring  the  shape  of  heads  born  in  face 
presentations,  found  that,  after  the  moulding  of  labour  had  passed 
off,  they  were  not  dolicho-cephalic.     Hecker,^  on  the  contrary,  who 

'  "  Do  la  Tete  du  F«;tus  au  point  de  vue  de  FObstetrique." 
''■  "  Ueber  die  Schadelform  bei  Gesichtslagen." 

21—2 


324 


The   Practice  of   Midwifery. 


attaches  much  hnportance  to  this  shape  of  the  child's  head,  has 
reported  instances  in  which  the  elongation  of  the  occiput  did 
persist  after  delivery.  It  is  clear,  however,  that  this  cause  is  not 
sufficient  by  itself,  as  the  anterior  arm  of  the  lever  is  always  longer 
than  the  posterior. 

Some  forms  of  foetal  monstrosity  produce  a  face  presentation 
during  pregnancy,  persisting  in  labour.  The  chief  of  these  are 
the  anencephalic  foetus,  and  the  foetus  deformed  by  tumour  of  the 
thyroid  gland. 

Any  accidental  cause  leading  to  a  partial  extension  may  produce 


Fig.  202. — Diagram  to  show  the  effect  of  obliquity  of  the  uterus  in  causing  face 

presentations. 

face  presentation,  since  the  resistances  will  complete  the  extension, 
if  once  it  has  passed  beyond  the  neutral  point  of  unstable  equi- 
librium (or  brow  presentation).  Such  a  partial  extension  may 
arise  from  a  sudden  gush  of  profuse  liquor  amnii,  which  is  present 
in  30  per  cent,  of  all  the  cases,  or  from  an  oblique  position  of  the 
child  in  the  uterus  at  the  time  when  the  membranes  rupture. 
This  is  more  likely  to  happen  when  the  child  is  dead,  for  then  there 
is  not  the  tonicity  of  flexor  muscles  which  maintains  the  chin-flexion, 
as  well  as  flexion  of  limbs,  in  the  usual  attitude  of  the  foetus.  Even 
a  want  of  tone  of  flexor  muscles  in  a  living  child  may  promote  it. 
Face  presentation  is  promoted   by   disproportion   between   the 


Face   Presentations.  325 

head  and  the  pelvis,  which  occurs  in  some  28  to  30  per  cent,  of  the 
cases,  for  i£  the  head  is  detained  above  the  brim,  displacement  is 
more  readily  produced  by  any  cause.  A  particular  form  of  pelvic 
deformity  may  actually  cause  it,  namely,  the  generally  flattened  or 
elliptic  pelvis,^  not  specially  contracted  in  the  conjugate  diameter. 
The  chief  resistance  may  then  be  at  the  ends  of  the  bi-parietal 
diameter,  especially  if  the  head  has  prominent  and  firmly  ossified 
parietal  tubera,  instead  of  at  the  ends  of  the  long  antero-posterior 
diameter,  or  that  opposed  to  the  conjugate  of  the  pelvis,  which  is 
generally  nearly  the  bi-temporal  diameter.  In  such  case,  the 
resultant  of  the  resistances  may  fall  posterior  to  the  condyles 
instead  of  in  front  of  them,  and  then  more  or  less  extension  will  be 
produced,  the  descent  of  occiput  being  more  resisted  than  that  of 
the  front  part  of  the  head. 

A  cause  of  face  presentation  which  is  now  generally  considered 
to  be  one  of  the  most  important  is  obliquity  of  the  uterus,  and 
therefore  of  the  propelling  force,  and  this  is  a  cause  which  may  be 
combined  with  any  of  the  others.  For  suppose  the  fundus  uteri 
to  be  inclined  to  the  right  side,  and  the  child  to  be  lying  with  its 
back  toward  the  right,  that  is,  in  the  second  or  third  position. 
The  propelling  force  is  then  inclined  toward  the  left,  and  therefore 
tends  to  push  the  condyles  in  that  direction,  or  toward  the  face  of 
the  child.  The  head  is  thus  pressed  against  the  left  pelvic  wall, 
and  the  reaction  of  the  pelvic  wall  forms  a  force  tending  to  push 
in  the  opposite  direction  (that  is,  toward  the  right  side  of  the 
pelvis,  and  toward  the  occiput  of  the  child)  either  the  forecoming 
part  of  the  head,  if  the  head  is  not  fully  engaged  in  the  pelvis, 
or  the  centre  of  the  head,  if  it  is  engaged.  In  either  case,  there 
is  thus  produced  what  in  mechanics  is  called  a  "  couple,"  that  is  a 
pair  of  equal  forces  acting  in  opiDosite  directions,  but  in  parallel, 
not  in  the  same  straight  lines  (Fig.  202).^  The  tendency  of  this 
pair  of  forces  is  not  to  move  the  centre  of  the  head,  but  to  rotate 
it  on  a  transverse  axis,  so  as  to  produce  extension.  If  the  obliquity 
of  the  propelling  force  is  considerable,  this  effect  may  overcome 
the  forces  tending  to  produce  flexion,  and  so  lead  to  fa,ce  presenta- 
tion. Similarly,  an  obliquity  of  the  uterus  toward  the  left  side 
tends  to  produce  extension  when  the  back  of  the  child  lies  toward 
the  left,  that  is,  in  the  first  and  fourth  positions. 

1  See  Chapter  XXIX. 

2  Each  of  the  forces  forming  the  couple  is  equal  to  the  component  of  the  propelling 
force  resolved  (by  the  piirallelogram  of  forces)  perpendicularly  to  the  axis  of  tlie  pelvis. 
The  oblique  propelling  force,  together  with  the  reaction  of  the  lateral  pelvic  wall,  is 
equivalent  to  a  force  acting  in  tiie  axis  of  the  pelvis,  tending  to  produce  onward  move- 
ment, and  the  couple,  tending  to  produce  rotation  on  a  transverse  axis,  that  is, 
extension. 


326  The   Practice  of   Midwifery. 

Statistics  afford  some  evidence  that  this  cause  is  actually  in 
operation.  For  in  vertex  presentation  left  dorsal  positions  pre- 
dominate in  the  proj)ortion  of  about  three  to  one,  but  in  face 
presentations  only  in  the  j)roportion  of  about  four  to  three.  It 
must  be  inferred  that  a  face  presentation  is  much  more  easily 
developed  out  of  a  vertex  when  the  back  of  the  child  lies  to  the 
right.  This  is  explained  by  the  usual  obliquity  of  the  fundus  uteri 
toward  the  right  side. 

A  sudden  reversal  of  the  lateral  obliquity  of  the  uterus  will 
have  a  much  greater  effect  than  a  persistent  obliquity.  Suppose 
the  woman  to  be  lying  on  the  left  side,  and  the  fundus  uteri 
to  be  inclined  toward  the  left  in  consequence,  the  child  lying 
in  the  second  j^osition,  with  its  face  to  the  left.  If  the  jDosition 
of  the  child's  head  corres^Donds  to  that  of  its  trunk,  lying  in  the 
axis  of  the  uterus,  the  occiput  will  then  be  tilted  to  the  right, 
and  the  face  will  be  more  inclined  over  the  brim  than  usual. 
Suppose  that  she  then  turns  to  the  right  side,  causing  a  right 
lateral  obliquity  of  the  uterus  and  of  the  trunk  of  the  foetus, 
and  that  a  pain  comes  on  at  that  moment.  The  foetal  head  will 
probably  not  at  once  accommodate  itself  to  the  position  of  the 
trunk,  and  will  be  in  a  position  of  partial  extension  ;  while  the 
uterine  contraction  will  produce  a  pair  of  forces  tending  to  cause 
further  extension. 

An  anterior  or  posterior  obliquity  of  the  uterus  acts  in  a  similar 
way  to  a  lateral  obliquity.  A  posterior  obliquity  of  the  uterus,  in 
reference  to  the  axis  of  the  brim,  which  in  some  degree  is  probably 
a  normal  condition  (see  p.  235),  tends  to  cause  extension  in  occii^ito- 
posterior  positions  (third  and  fourth),  an  anterior  obliquity  (such  as 
occurs  from  pendulous  abdomen)  in  occipito-anterior  positions  (first 
and  second).  Here  again  we  find  that  third  and  fourth  positions 
are  relatively  commoner  in  face  than  in  vertex  presentations,  while 
posterior  obliquity  of  the  uterus  is  more  usual  than  anterior,  and 
thus  the  theory  of  causation  by  obliquity  of  propelling  force  is  again 
confirmed.  This  view  is  strengthened  by  the  fact  that  face  presen- 
tations recur  in  the  same  patient  in  about  8  per  cent,  of  the  cases.^ 

Varieties  of  Face  Presentations.— In  face,  as  in  vertex  presen- 
tation, there  are  four  positions,  each  of  which  is  developed  out  of 
the  corresponding  position  of  the  vertex  by  extension  of  the  head. 
It  is  usual  to  name  them  from  the  position  of  the  chin  {e.g.,  left 
mento-anterior). 

The  four  following  will  then  be  the  positions  of  the  face : — 
First  or  Right  Mento-jJosterior,  R.  M.  P. — The  long  diameter  of 
1  Wullstein,  Die  Gesichtslage,  I.  Dissert.,  Berlin,  1891. 


Face  Presentations. 


327 


the  head  approximates  towards  the  right  oblique  diameter  of  the 
pelvis.  The  chin  points  toward  the  right  sacro-ihac  articulation, 
the  forehead  toward  the  left  foramen  ovale. 

Second  or  Left  Mento-posterior,  L.  M.  P. — The  long  diameter  of 
the  head  approximates  toward  the  left  oblique  diameter  of  the 
pelvis.  The  chin  points  toward  the  left  sacro-iliac  articulation, 
the  forehead  toward  the  right  foramen  ovale. 

Third  or  Left  Mento-anterior,  L.  M.  A. — The  long  diameter  of  the 
head  approximates  toward  the  right  oblique  diameter  of  the  pelvis. 
The  chin  points  toward  the  left  foramen  ovale,  the  forehead 
toward  the  right  sacro-iliac  articulation. 

Fourth  or  Right  Mento-anterior,  K.  M.  A. — The  long  diameter  of 
the   head  approximates   toward  the  left  oblique   diameter  of  the 


Fig.  203.— Rotation  of   chin  under  pubic  arch  in  face  presentation. 

pelvis.  The  chin  points  toward  the  right  foramen  ovale,  the  fore- 
head toward  the  left  sacro-iliac  articulation. 

As  in  the  vertex  positions,  the  first  and  third  and  the  second  and 
fourth  are  the  reverse  of  each  other.  The  first  position  is  still  the 
commonest,  but  only  in  slight  proportion.  The  fourth  is  relatively 
not  so  rare  as  in  vertex  presentations.  The  reason  for  the  differences 
has  already  been  explained. 

In  comparing  any  position  with  the  corresponding  position  of 
the  vertex,  it  must  be  noted  that  the  words  right  and  left,  anterior 
and  posterior,  are  reversed,  because  the  face  position  is  named  by 
its  anterior  extremity,  the  vertex  by  its  posterior.  Thus  the  first 
vertex  position,  or  left  occipito-anterior,  becomes  by  extension  the 
first  face  position,  or  right  mento-posterior.     It  will  be  seen  shortly, 


328 


The   Practice  of   Midwifery. 


however,  that  the  right  mento-posterior  position  of  the  face  corre- 
sponds mechanically  to  the  right  occipito-posterior  or  third  position 
of  the  vertex,  the  chin  being  the  most  prominent  part  of  the  one, 
the  vertex  of  the  other.     Similarly  for  the  other  three  positions. 

Mechanism  of  Labour  in  Face  Presentation. 

The  mechanism  of  the  passage  of  the  head  will  first  be  described 
for  the  case  in  which  the  face  lies  in  the  first  or  right  mento- 
posterior position.  As  in  the  case  of  the  vertex,  five  principal 
subsidiary  movements  take  place  in  conjunction  with  the  movement 


"^-v. 


Fig.  204. — Distension  of  intact  perineum  in  face  presentation.  Tlie  elongation 
of  occiput  produced  by  protracted  labour  is  also  shown.  B.  Bladder. 
2  S.  Second  sacral  vertebra.  R.  Rectum,  a.  Anus.  /.  Fourchette. 
m:  Orifice  of  urethra.     (After  Schroeder.) 

of  descent  of  the  centre  of  the  head  along  the  curved  axis  of  the 
pelvis.     These  are  enumerated  as  follows  : — 

Extension. 
Internal  Kotation. 
Descent  -i   Flexion. 

Eestitution. 
^  External  Rotation. 


Extension.— It  has  already  been  explained  that  the  posterior 
arm  of  the  head-lever,  instead  of  the  anterior,  is  now  the  longest. 
The  resistances  therefore  produce  progressive  extension  instead  of 


Face   Presentations. 


329 


flexion,  the  resistance  to  the  forehead  having  the  mechanical 
advantage  over  that  to  the  chin,  until  the  chin  becomes  the  most 
advanced  point,  and  extension  is  at  last  checked  by  the  occiput 
being  compressed  against  the  back  (see  Fig.  201,  p.  823).  Not  only 
the  action  of  the  head-lever,  but  the  shape  of  the  presenting  part,  is 
the  reverse  of  that  in  vertex  presentations.  The  anterior  extremity, 
the  chin,  instead  of  the  posterior,  is  now  the  most  jDrominent  and 
projecting  part,  the  forehead  being  more  gradually  rounded.  Hence 
the  chin  in  face  presentation  corresponds  mechanically  to  the  occiput 
in  vertex  presentation.  When  the  face  is  lying  over  a  not  quite 
fully  expanded  os  uteri,  this  shape  of   the  presenting  part  also 


Fig.  205. — Passage  of  the  head  under  the  pubic  arch  by  a  movement  of  flexion 
in  face  presentation. 

favours  extension,  just  as  the  shape  of  the  vertex  favours  flexion  in 
vertex  presentations  (see  pp.  248,  249). 

Internal  Rotation. — The  chin,  descending  in  advance  of  the 
forehead,  is  the  first  to  meet  the  resistance  of  the  inclined  plane 
formed  by  the  soft  parts  at  the  posterior  part  of  the  pelvic  floor 
(see  Fig.  132,  p.  221),  and  by  it  is  pushed  forward  into  the  free 
space  under  the  pubic  arch,  just  as  the  occiput  is  usually  pushed 
forward  in  occipito-posterior  positions.  The  chin  then  comes  to 
be  directed  almost  exactly  forward,  as  shown  in  Figs.  204,  205. 
Thus  the  internal  rotation  takes  place  through  nearly  three-eighths 
of  a  circle.  The  first  position  of  the  face  corresponds  mechanically 
to  the  third  position  of  the  vertex,  and  is  converted  into  the  fourth 


330 


The   Practice  of   Midwifery. 


position  of  the  face  by  a  loufi  rotation,  just  as  the  third  of  the 
vertex  is  converted  into  the  second.  Like  the  occiput  in  occipito- 
posterior  positions,  the  chin  may  be  rotated  forward  either  early  or 
late,  but  more  frequently  late.  Early  rotation,  when  it  occurs,  is 
due  to  the  pressure  of  the  upper  part  of  the  elastic  pelvic  floor. 
When  extension  is  incomplete,  rotation  is  more  likely  to  be  delayed ; 
and  for  a  time,  in  the  earlier  part  of  its  descent,  the  chin  may  be 
rotated   somewhat   backward,   in   consequence   of    the    screw-like 


Fig.  206. — Arrest  of  head,  neck,  and  shoulders  in  plane  of  brim  in  persistent 
mento-posterior  presentation. 


shape  of  the  bony  pelvis,  the  posterior  inclined  plane  of  the 
ischium  directing  the  chin  backward,  if  the  presenting  part  fits 
tightly. 

It  hardly  ever  happens  that  the  chin  remains  posterior  like  the 
occiput  in  unreduced  occipito-posterior  positions.  It  is  scarcely 
possible  for  the  head  to  be  delivered  spontaneously  in  this  way, 
unless  it  is  excessively  small  in  relation  to  the  genital  canal,  or  the 
perineum  extremely  deficient,  because,  in  order  that  the  chin  might 
escape  over   the   anterior   margin   of   the  perineum,  it  would   be 


Face   Presentations.  331 

necessary  for  the  neck  and  shoulders  of  the  fcetus  to  enter  the  cavity 
of  the  pelvis  at  the  same  time  as  the  head,  which  in  a  normal-sized 
pelvis  is  impossible  unless  the  child  is  very  small.  Sometimes, 
however,  a  small  head  may  be  delivered  artificially  in  this  position, 
the  chin  being  hooked  over  the  perineum.  Sometimes  the  rotation 
only  occurs  just  as  the  face  passes  the  outlet,  and  the  chin  may 
then  escape  almost  in  a  lateral  position,  the  internal  rotation  being 
incomjjlete. 

The  mechanism  of  the  second  position  of  the  face  corresponds 
exactly  to  that  of  the  first,  right  and  left  being  interchanged.  In 
the  third  position  the  chin  has  only  to  rotate  through  about  one- 
eighth  of  a  circle,  until  it  is  directed  nearly  forward,  and  the 
mechanism  corresj)onds  to  that  of  the  first  position  of  the  vertex, 
a  short  rotation  occurring  in  each  case.  In  this  case,  the  inclined 
plane  of  the  pelvic  floor  guides  the  chin  forward  in  the  earlier  part 
of  the  descent  of  the  head.  The  mechanism  of  the  fourth  position 
corresponds  to  that  of  the  third,  right  and  left  being  inter- 
changed. It  is  equivalent  mechanically  to  the  second  position  of 
the  vertex. 


Flexion. — The  fore-coming  part  of  the  head  is  pushed  forward 
as  soon  as  it  meets  the  inclined  plane  at  the  floor  of  the  pelvis. 
The  after-coming  part  of  tlie  head  is  prevented  from  moving 
forward  by  the  resistance  of  the  pubes,  and  by  its  attachment  to 
the  neck.  Hence,  since  the  front  of  the  child  is  now  directed 
forward,  the  chin  either  having  rotated  forward,  or  being  anterior 
from  the  first,  a  movement  of  flexion  is  produced,  as  at  the 
termination  of  unreduced  occipito-posterior  positions  of  the  vertex 
(see  p.  260).  The  chin  escapes  under  the  pubic  arch,  while  first  the 
forehead  and  then  the  bregma  and  occiput  pass  over  the  perineum 
(Fig.  205,  p.  329).  The  forehead  moves  faster  than  the  chin, 
having  to  go  along  the  outside  of  the  curve,  while  the  chin  moves 
along  the  inside,  but  the  chin  is  not  arrested.  The  greatest 
diameter  of  the  foetus  opposed  to  any  antero-posterior  diameter  of 
the  genital  canal  is  one  which  passes  through  the  posterior  part  of 
the  head  behind  the  anterior  fontanelle,  since  in  this  the  thickness 
of  the  neck  has  to  be  included  (see  Fig.  204,  p.  328). 


Restitution. — As  in  vertex  presentations,  as  soon  as  the  head  is 
released  the  face  generally  turns  again  towards  the  side  which  it 
originally  occupied  to  accommodate  itself  to  the  position  of  the 
slioulders. 


332 


The  Practice  of   Midwifery. 


External  Rotation. — As  the  shoulders  rotate  m  then-  passage 
through  the  pelvis,  and  their  bis -acromial  or  transverse  diameter 
turns  into  the  antero-posterior  diameter  of  the  pelvic  outlet,  the 


r.mii 


Fig.  207. — Diagram   of   mechanism   of    labour   in   face   presentation.     (For 

explanation  of  general  scheme  of  diagram,  see  Fig.  159.)     < =  fronto- 

mental  diameter  of  face,  semicircle  =  chin  ;  \—  =  bis-acromial 
diameter  of  shoulders  ;  short  limb  =  right  shoulder  ;  i.,  r.m.p. ,  first  face, 
fr.  ment.  diam.  in  rt.  obliq.  diam.,  bis-acr.  diam.  in  left  oblique  ; 
ii.,  internal  rotation  of  chin  through  \  of  circle  forwards  ;  iii.,  further 
rotation  of  chin,  and  conversion  into  fourth  face  presentation  ;  iv.,  chin 
rotated  under  symphysis  pubis  ;  v.,  face  born  by  movement  of  exten- 
sion, chin  leading:  vi.,  restitution,  movement  of  chin  toM^ards  original 
direction;  vii.,  external  rotation  of  face  with  internal  rotation  of 
shoulders  ;  viii.,  birth  of  shoulders,  right  shoulder  leading. 


rotation  of  the  face  takes  place  still  further  in  conformity  with  the 
rotation  of  the  shoulders,  so  that  in  the  first  and  fourth  presenta- 
tions it  looks  towards  the  right  thigh,  and  in  the  second  and  third 
towards  the  left  thigh,  of  the  mother. 


Face  Presentations. 


333 


Lateral  Obliquities  in  Face  Presentation. — Lateral  or  Naegele- 
obliquity  of  the  head  is  not  so  often  observed  in  face  as  in  vertex 
presentation,  because  the  large  bi-parietal  diameter  is  now  situated 
nearer  to  the  after-coming  than  to  the  fore-coming  part  of  the 
head.  It  may,  however,  occur  in  some  cases  where  labour  is 
difficult,  or  the  pelvis  contracted,  especially  when  posterior  obliquity 
of  the  uterus,  in  reference  to  the  axis  of  the  brim,  exists,  and  the 
anterior  side  of  the  face  then  becomes  deepest  in  reference  to  the 


Fig.  208. — Successive  stages  of  first,  or  right  mento-posterior,  position  of  face. 


plane  of  the  brim.  In  the  later  stage,  the  chin-flexion  of  the  head, 
on  approaching  the  outlet,  is  accompanied  by  some  lateral  flexion 
toward  the  anterior  shoulder,  just  as  the  extension  of  the  head  is, 
in  vertex  presentations,  toward  the  outlet  of  the  canal  of  soft  parts 
(see  p.  265),  and  for  the  same  reason. 

Contrasts  between  the  Mechanism  of  Face  and  Vertex 
Presentations. — It  will  thus  be  seen  that  while  the  mechanism  of 
delivery  in  face  and  vertex  presentations  is  closely  analogous  in  many 
respects,  it  is  contrasted  in  the  following  particulars  : — In   face 


334 


The  Practice  of   Midwifery. 


presentation  extension  takes  the  place  of  flexion  in  the  earlier  stage, 
and  flexion  takes  the  place  of  extension  in  the  later  stage.  In 
vertex  presentations,  the  commoner  positions,  the  occipito-anterior, 
are  the  more  favourable,  a  short  rotation  only  being  required ;  in 
face  presentations,  the  commoner  positions,  the  mento-posterior, 


^'m.-il. 


Fig.  209. — Diagram  of  mechanism  of  labour  of  second  face  presentation, 
showing  its  conversion  into  the  third  face,  and  the  mechanism  of  the 
latter.     (Symbols  as  in  Fig.  207.) 


are  the  less  favourable,  a  long  internal  rotation  being  required.  In 
vertex  presentations,  the  first  and  second  positions  remain  un- 
changed ;  the  third  and  fourth  are  generally  converted  into  the 
second  and  first  respectively.  In  face  presentations,  the  first  and 
second  positions  are  almost  invariably  converted  into  the  fourth  and 
third  respectively  ;  the  third  and  fourth  remain  unchanged. 

Descent  is  accompanied  by  extension  and  internal  rotation  till 


Face  Presentations. 


335 


the  chin  is  beginning  to  approach  the  pubic  arch.     Then  flexion  is 
substituted  for  extension  ;  and  descent,  internal  rotation,  and  flexion 


Fig.  210. — Moulding  of  head  in  face  presentation.     The  continuous  outline 
shows  the  head  before  moulding.     (After  Budin.) 


Fig.  211. — Moulding  of  head  in  face  presentation.  The  continuous  outline 
shows  the  head  before,  the  dotted  line  after,  moulding.  F  0,  fronto-occi- 
pital  diameter  ;  M  0,  mento-occipital  ;  SO  —  B,  sub-occipito-bregmatic, 
(After  Budin.) 

go  on  together  till  the  head  has  escaped  at  the  vulva.  Then 
external  rotation  is  substituted  for  its  opposite,  internal  rotation. 
The  successive  stages  of  a  mento-posterior  position  are  shown  in 
Fig.  208  (p.  333). 


33^ 


The  Practice  of   Midwifery. 


Caput  Succedaneum  in  Face  Presentation. — The  swelling 
upon  the  presenting  part  is  often  very  considerable  in  face  presenta- 
tion, labour  being  generally  more  protracted  than  in  vertex  pre- 
sentation. The  features  thus  become  excessively  distorted,  the  lips 
being  enormously  swollen,  and  the  eyelids  also  swollen  so  much  that 
the  eyes  are  closed  at  birth.  There  may  be  also  effusion  of  blood 
in  the  conjunctivae.  While  the  chin  is  posterior,  the  centre  of  the 
caput  succedaneum  formed  is  near  the  eye ;  in  mento-anterior 
positions,  or  after  rotation  of  the  chin  forward,  it  is  at  the  lower 


Fig.  212.  —  Face  presentation;  «,  first  position;  5,  second  position. 
(Farabeuf  and  Varnier.)  The  arrow  indicates  the  line  of  forward 
rotation.     Patient  in  usual  obstetric  position. 


part  of  the  cheek  near  the  angle  of  the  mouth, 
features  passes  off  in  a  few  days. 


The  swelling  of  the 


Moulding  of  the  Head  in  Face  Presentation. — The  moulding 
of  the  head  in  face  presentation  is  shown  in  Fig.  211,  taken  from 
Budin's  measurements.  The  convexity  of  the  frontal  and  occipital 
bones  is  increased,  while  the  parietal  bones  are  flattened,  so  that 
the  curvature  of  the  sagittal  suture  is  diminished.  The  squamous 
portion  of  the  occipital  bone  is  rotated  backward,  so  that  the 
occipital  protuberance  becomes  unusually  prominent.  The  chief 
diminution  is  in  the  vertical  or  cervico-bregmatic,  and  in  the  sub- 
occipito-bregmatic  diameters  (s.o. — b)  ;  the  compensatory  increase 
is  chiefly  in  the  fronto-occipital  diameter  (f  o),  but  there  is  slight 
increase  also  of  the  mento-occipital  (m  o).     Fig.  204  (p.  328)  also 


Face  Presentations. 


337 


shows  the  relation  which  the  moulding  of  the  head  has  to  the 
pressure  of  the  genital  canal.  The  prominence  at  the  anterior  part 
of  the  forehead  (shown  in  Fig.  210),  generally  seen  after  face  pre- 
sentation, does  not  seem  easy  to  account  for,  except  on  the  view 
that  it  is  formed  when  the  case  is  going  through  the  stage  of  brow 
presentation,  at  which  time  the  forehead  is  the  most  unsuj^ported 
part.  The  extension  of  the  head  of  the  foetus  on  the  trunk  some- 
times persists  for  several  days  after  birth. 

Diagnosis. — The  face  may  be  distinguished  from  the  vertex,  even 
before  the  rupture  of   the  membranes,  by  the  unevenness  of  the 


Fig.  21.3.  —  Face  presentation;  a,  third  position;  &,  fourth  position. 
(Farabeuf  and  Varnier.)  The  arrow  indicates  the  line  of  forward 
rotation.     Patient  in  usual  obstetric  position. 

features,  compared  with  the  uniform  hardness  of  the  cranial  bones. 
As  a  rule,  however,  a  face  presentation  is  not  fully  developed  until 
the  membranes  have  ruptured,  and  the  resistance  comes  into  play. 
Whenever  there  is  even  a  suspicion  that  the  face  is  presenting,  the 
utmost  care  and  gentleness  must  be  used  in  vaginal  examination,  to 
avoid  the  risk  of  injuring  the  eyes.  The  diagnosis  of  face  presenta- 
tion by  abdominal  palpation  has  already  been  described  (p.  273). 
When  the  head  is  high  up,  and  the  chin  directed  backwards,  the 
back  of  the  head,  and  the  depression  between  it  and  the  child's 
back,  may  be  made  out  a  little  above  the  brim  towards  one  side  of 
the  front  of  the  pelvis,  especially  if  bimanual  examination  is 
employed.  The  fcetal  heart  will  be  heard  most  distinctly  on  the 
M.  22 


338 


The   Practice  of   Midwifery. 


same  side  as  that  on  which  the  limbs  are  felt,  instead  of  on  the 
opposite  side,  as  in  vertex  presentations  (see  p.  275).  Cases  of  face 
presentations  have  been  recorded  in  which  the  pulsations  of  the 
foetal  heart  have  been  felt  through  the  mother's  abdomen.^ 

The  only  other  part  which  might  possibly  be  mistaken  for  the  face 
on  vaginal  examination  is  the  breech.     The  distinctive  points  to  be 

sought  for  on  the  face  are  the 
root  of  the  nose,  the  openings 
of  the  nostrils,  the  hard, 
toothless,  alveolar  ridges  in 
the  mouth,  and  the  chin.  In 
the  breech,  the  anus,  grasping 
the  finger  with  its  sphincter, 
the  bony  prominences  of  the 
sacrum,  and  the  presence  of 
thick  meconium,  undiluted 
with  liquor  amnii,  are  dis- 
tinctive. 

Prognosis  in  Face  Pre- 
sentation.— The  prolongation 
of  labour  common  in  face 
presentation  renders  the  prog- 
nosis much  more  unfavour- 
able for  the  child  than  in 
vertex  presentation.  Thus, 
in  166  cases  of  face  presenta- 
tion in  the  Guy's  Hospital 
Lying-in  Charity,  the  propor- 
tion of  children  still-born  was 
^^^^  8'4  per  cent.     In  vertex  pre- 

FlG.2U-Lmeof  section  and  shape  of  the       ggntations    during     the     same 
mento-vertical    plane.       (Edgar,    from         _  .  . 

lead-tape  tracings,  Practice  of  Obstetrics,       time,  the  proportion  of  children 

^^'      '-^  still-born  (including  premature 

children)  was  only  2-7  per  cent.  Out  of  these  166  cases  of  face 
presentation,  artificial  delivery  was  found  necessary  in  seven.  One 
child  was  delivered  by  version,  four  by  forceps,  two  by  the  cepha- 
lotribe.  All  of  the  mothers  recovered.  It  is  generally  considered, 
however,  that  in  face  presentation  the  prognosis  for  the  mother  is 
also  somewhat  more  unfavourable  than  in  vertex  presentation,  but 
the  difference  is  not  nearly  so  great  as  in  the  case  of  the  child. 

1  Fischel,  Prag.  Med.  Wochsenschr.,  1881,  No.  12  ;  Duval,  Johns  Hopkins  Hospital 
Bulletin,  October,  1897,  p.  207. 


Face  Presentations.  339 

In  reference  both  to  mothers  and  children,  it  is  to  be  remembered 
that  the  pelvis  is  more  often  contracted  in  face  than  in  vertex 
presentation.  According  to  Hecker/  the  maternal  mortality  is 
3'7  per  cent.,  and  the  foetal  8'7  per  cent. 

Brow  Presentation. — It  has  already  been  mentioned  that 
brow  presentation  constitutes  the  position  of  unstable  equilibrium, 
in  which  the  two  arms  of  the  head-lever  exactly  balance  each 
other,  so  that  the  propulsive  force  has  no  tendency  to  produce 
either  flexion  or  extension  (see  p.  323).  The  prominence  of  the 
forehead  forms  the  centre  of  the  presenting  part,  and  the  anterior 
fontanelle  can  generally  be  reached  in  one  direction,  the  nose  or 
even  the  chin  in  the  other.  The  large  mento-occipital,  or  even 
the  maximum  vertico-mental  (see  p.  132)  diameter  of  the  head,  is 
thrown  almost  exactly  across  the  pelvis.  This  is  generally  too 
large  for  the  pelvis  to  admit,  and  hence  it  is  usually  only  when 
the  head  has  not  yet  fully  entered  the  brim  that  brow  presenta- 
tion is  observed.  In  the  unstable  equilibrium  of  brow  presentation, 
if  there  is  the  slightest  variation  either  in  the  degree  of  flexion  of 
the  head  or  in  the  inclination  of  the  propulsive  force,  the  tendency 
either  to  extension  or  flexion  will  begin  to  predominate.  Hence 
the  head  can  never  possibly  pass  through  the  genital  canal  in  a 
position  of  brow  presentation,  even  if  the  pelvis  is  large  enough  to 
admit  the  maximum  vertico-mental  diameter  of  the  head.  Almost 
always  the  change  is  into  face  presentation,  since  the  cause,  what- 
ever it  may  be,  which  has  already  produced  undue  extension, 
generally  goes  on  to  produce  complete  extension  into  face  pre- 
sentation. I  have  known  a  case,  however,  in  which  the  presentation 
was  partially  converted  into  a  face,  and  the  chin  rotated  forward. 
The  vertex  then  came  down,  and  the  head  was  delivered  in  the 
occipito-posterior  position  of  the  vertex.  But  though  the  head 
never  passes  through  the  pelvis  in  a  position  of  brow  presentation, 
it  is  sometimes,  although  rarely,  arrested  in  that  position,  any 
slight  advantage  which  one  or  other  arm  of  the  head-lever  may  gain 
at  any  time  not  being  sufficient  to  overcome  friction  and  move  the 
head. 

Disproportion  between  the  child  and  the  pelvis,  dorsal  dis- 
placement of  the  arm,  premature  rupture  of  the  membranes  followed 
by  the  contraction  of  the  uterus  tightly  round  the  trunk  of  the 
taitu.8,  are  some  of  the  conditions  likely  to  lead  to  a  persistence  of 
a  brow  presentation. 

1  V.  Hecker,  "  Statistiches  aus  der  GebLirtenstalt  Miinclien,"  Archivf.  G^'niilc,  1882, 
Bd.  20,  s.  378. 

22—2 


340  The   Practice  of   Midwifery. 

If  a  brow  presentation  remains  unconverted,  the  prognosis  is  grave 
both  for  the  mother  and  the  child,  the  maternal  mortality  being  as 
high  as  5  per  cent.,  and  that  of  the  children  20  to  30  per  cent. 

Out  of  49,145  deliveries  in  the  Guy's  Hospital  Lying-in  Charity 
brow  presentation  was  observed  in  thirty  cases.  Of  these  twenty- 
five  were  delivered  spontaneously,  the  presentation  being  generally 
converted  into  a  face  ;  three  children  were  delivered  by  version, 
two  by  forceps.  Thus  the  proportion  of  brow  presentation  was  1 
in  1,638. 

Moulding  of  the  Head  in  Brow  Presentation. — The  general 
character  of  the  moulding   produced   in   brow  presentation  is  an 


r 


Fig.  215. — Moulding  of  head  in  brow  presentation. 

exaggeration  of  that  seen  in  face  presentation  (Fig.  210,  p.  335). 
In  brow  presentation  the  whole  of  the  forehead  becomes  more 
convex  and  prominent,  instead  of  merely  its  anterior  part.  The 
flattening  of  the  parietal  bones  along  the  line  of  the  sagittal  suture 
is  carried  much  further  than  that  shown  in  Fig.  210,  and  so  also 
is  the  prominence  and  convexity  near  the  occipital  protuberance. 
A  large  caput  succedaneum  is  generally  formed,  having  its  centre 
near  the  prominence  of  the  forehead. 

Treatment  of  Face  Presentations. — The  first  point  to  be 
regarded  is  to  keep  the  membranes  intact  as  long  as  possible. 
The  reason  for  this  is,  first,  that  the  face  does  not  form  so  good 
a  dilator  of  the  soft  parts  as  the  vertex  ;  and,  secondly,  that  it  is 
more   liable  than  the  vertex  to  injurious  results  from  pressure. 


Face  Presentations.  341 

Most  frequently,  however,  face  presentation  is  only  discovered  after 
rupture  of  the  membranes. 

In  the  latter  stage,  the  general  principle  is  to  leave  the  case 
as  much  as  possible  to  nature,  and  to  be  content  to  allow  the 
labour  to  be  more  protracted  than  in  vertex  presentation.  It 
was  formerly  recommended  either  to  perform  version,  or  to 
attempt  to  convert  the  face  into  a  vertex  presentation.  To  the 
latter  plan  it  is  a  great  objection  that  if  the  attempt  only 
partially  succeeds,  as  is  very  probable,  the  head  is  brought  into 
the  more  unfavourable  position  of  brow  presentation.  That 
interference  is  generally  quite  unnecessary  is  proved  by  the 
statistics  of  the  Guy's  Hospital  Lying-in  Charity  already  quoted, 
in  which  nearly  96  per  cent,  of  the  cases  were  terminated 
naturally.  This  is  a  larger  proportion  than,  in  the  present  day, 
is  generally  allowed  to  be  terminated  without  assistance  in  vertex 
presentation. 

Before  the  rupture  of  the  membranes,  indeed,  an  attempt  may 
safely  be  made  to  rectify  the  position  of  the  child  by  external 
manipulation,  if  its  exact  position  can  be  positively  made  out,  and 
especially  if  the  occiput  can  be  felt  above  the  brim.  In  face 
presentation  the  chest  is  thrown  forward  against  the  uterine  wall, 
while  the  shoulders  are  separated  from  it,  at  the  opposite  side  of 
the  uterus,  by  a  space  posterior  to  the  child.  The  method  to  adopt, 
therefore,  is  to  press  with  the  fingers  of  one  hand  through  the 
abdominal  and  uterine  walls  upon  the  chest,  directing  it  towards 
the  back  of  the  child,  and  somewhat  upwards  as  regards  the  uterine 
axis,  until  the  shoulders  and  back  are  brought  against  the  uterine 
wall,  and  the  head  thereby  necessarily  flexed.  At  the  same  time, 
the  other  hand  makes  counter-pressure  uj)on  the  occiput,  felt  above 
the  brim,  directing  it  toward  the  front  of  the  child  and  downward. 
Schatz  ^  recommends  the  counter-pressure  to  be  made  upon  the 
breech,  directing  it  toward  the  front  of  the  child,  but  such  pressure 
would,  if  anything,  tend  to  lower  the  chin  rather  than  to  raise  it. 
This  method  of  replacement  is  likely  to  be  j^i'acticable  only  if  the 
chin  is  directed  forward  or  to  one  side,  not  if  it  is  directed  much 
backward,  because  then  the  surface  of  the  uterus  corresponding  to 
the  chest  of  the  child  cannot  be  reached. 

In  these  circumstances  it  has  been  recommended  by  Thorn  and 
others  to  introduce  the  hand  into  the  uterus  and,  by  pressure  first 
on  the  forehead  and  then  on  the  face,  to  attempt  to  convert  the 
presentation  into  an  occiput,  the  other  hand  being  employed  to 
press  on  the  occiput  through  the  abdomen,  and  an  assistant  at  the 

'^  "Die  Urnwandlung  von  Gesichtslage,"  Arcli.  i'iir  (Jjnak.,  B.  V.,  p.  313. 


342  The  Practice  of   Midwifery. 

same  time  making  pressure  on  the  child's  chest.-"-  When  we 
remember,  however,  the  very  high  percentage  of  natural  deliveries 
in  face  presentations  we  shall  be  very  loth  to  interfere. 

Management  of  Mento-posterior  Positions. — The  management 
of  mento-posterior  positions  precisely  corresponds  mechanically  to 
that  of  occipito-posterior  positions  of  the  vertex.  If  the  rotation 
forward  of  the  chin  does  not  readily  take  place,  it  is  to  be  aided 
indirectly  by  promoting  extension,  just  as  the  rotation  of  the 
occiput  forward  is  aided  by  promoting  flexion.  This  is  to  be  done 
chiefly  by  pressing  the  forehead  upward  and  somewhat  backward 
during  a  pain.  From  time  to  time  also,  the  chin  may  be  drawn 
downward  and  somewhat  forward  by  two  fingers  hooked  over  it 
in  the  interval  of  pains. 

Extension  may  also  be  favoured  by  placing  the  woman  on  her 
left  side,  in  the  first  and  fourth  positions,  when  the  child's  back  is 
toward  the  left,  and  on  her  riglit  side,  in  the  second  and  third 
positions,  when  the  back  is  toward  the  right.  For  suppose  the 
child  in  the  second  or  left  mento-posterior  position  of  the  face 
(see  Fig.  199,  p.  321),  and  the  woman  placed  on  her  right  side. 
The  breech  tends  to  fall  over  toward  the  right,  and  the  expulsive 
force  therefore  becomes  directed  somewhat  obliquely  toward  the 
anterior  end  of  the  head-lever,  and  toward  the  left  side  of  the 
mother.  Thus  the  anterior  arm  of  the  head-lever  is  shortened, 
and  the  posterior  increased.  This  increases  the  mechanical  advan- 
tage which  the  resistance  to  the  forehead  has  over  the  resistance 
to  the  chin  (see  Fig.  201,  p.  323).  Another  plan  may  be  tried 
before  recourse  is  had  to  instrumental  delivery.  The  whole  hand 
is  introduced  into  the  vagina,  the  fingers  on  one  side  of  the  face, 
the  thumb  on  the  other.  The  head  is  thus  grasped  and  the  chin 
rotated  to  the  front  under  an  anaesthetic.  If  this  method  fail,  an 
attempt  may  be  made  to  rotate  the  chin  to  the  front  with  the  help 
of  the  vectis  (see  Chap.  XXXIII.). 

Treatment  of  Protracted  Labour  in  Face  Presentation. — If  the 
chin  is  directed  forward,  forceps  may  be  applied  without  hesitation 
if  there  is  indication  for  their  use.  If,  however,  the  chin  is  directed 
backward  or  to  one  side,  there  is  the  disadvantage  that  one  blade 
is  apt  to  compress  the  larynx  or  trachea,  and  the  child's  life  is  then 
likely  to  be  sacrificed.  Under  these  circumstances,  therefore,  more 
patience  should  be  exercised  than  in  vertex  presentations.  The 
foetal  heart  should  be  carefully  watched,  and  on  the  first  appearance 

1  Thorn,  Zeitschr.  f.  Geb.  u.  Gyniik.,  1895,  Bd.  31,  s.  1. 


Face  Presentations.  343 

of  any  danger  to  the  life  of  the  mother  or  of  the  child  artificial  aid 
should  be  given.  If  the  head  is  sufficiently  high  in  the  pelvis, 
an  attempt  may  be  made  to  convert  the  presentation  into  a  vertex, 
after  the  method  recommended  by  Thorn,  or  rotation  of  the  chin 
forwards  may  be  carried  out  either  manually  or  by  the  use  of  the 
vectis.  When  the  head  is  high  up,  the  uterus  not  firmly  con- 
tracted, and  especially  when  there  is  any  contraction  of  the 
conjugate  diameter  of  the  pelvis,  version  may  be  preferred. 
Otherwise  extraction  by  forceps,  preferably  by  axis  traction  forceps, 
should  be  tried,  and  if  this  does  not  succeed,  then  as  a  last  resource 
craniotomy  must  be  performed. 

Some  operators  have  practised  pubiotomy  or  symphysiotomy 
in  these  cases,  but  since  the  life  of  the  child  has  generally  been 
endangered  by  attempts  at  delivery,  such  a  procedure  could  hardly 
ever  be  justifiable. 

Of  75  cases  of  mento-posterior  presentations  collected  by  Reed, 
eight  of  the  mothers  died  and  30  of  the  children.  In  29  of  these  cases 
rotation  was  effected  either  manually  or  after  the  application  of  the 
forceps,  in  14  the  presentation  was  successfully  converted  into 
a  vertex,  and  in  31  the  child  was  delivered  with  the  chin  remaining 
posterior  by  the  use  of  the  forceps.  In  14  of  the  cases,  however,  all 
other  means  failed  and  craniotomy  had  to  be  performed. 

Treatment  of  Brow  Presentation. — Since  by  far  the  greater 
number  of  brow  presentations  end  spontaneously  by  conversion 
into  face  presentation,  the  physician  may  exercise  a  fair  amount 
of  patience,  to  see  what  nature  will  do,  so  long  as  the  mother's 
condition  is  satisfactory  and  the  foetal  heart  beating  naturally. 
As  in  the  case  of  face  presentation,  extension  will  be  aided  if  the 
woman  is  placed  on  that  side  toward  which  the  hack  of  the  child 
is  directed;  for  the  breech  will  fall  over  toward  that  side,  the 
propelling  force  will  be  directed  somewhat  obliquely  toward  the 
front  of  the  child,  and  so  the  anterior  arm  of  the  head-lever 
(see  Fig.  201,  p.  323)  will  be  shortened,  and  the  posterior  arm 
lengthened. 

The  conversion  will  fail  only  when  the  advance  of  the  head  is 
arrested.  When  it  is  so  arrested,sufficient  time  should  be  allowed 
for  the  head  to  become  moulded,  and  then  extraction  by  forceps 
may  be  tried.  As  in  face  presentations,  the  most  favourable  case 
for  their  use  is  that  in  which  the  chin  is  directed  forward.  In 
some  cases  it  may  l^e  possible  to  convert  the  case  into  one  of  vertex, 
or  of  face  presentation,  by  drawing  down  the  occiput  or  the  chin 
by  fingers  or  vectis,  or  by  Thorn's  method  ;  or  if  the  head  is  high 


344  The  Practice  of   Midwifery. 

up,  and  the  uterus  not  firmly  contracted,  version  maybe  performed. 
Failing  success  by  one  or  other  of  these  means,  the  only  resource 
is  craniotomy. 

Of  191  cases  of  brow  presentation  collected  by  Heinricius,  45,  or 
23'5  per  cent.,  of  the  children  were  born  dead.^ 

1  Reed,  Amer.  Journ.  Obstet.,  1905,  Vol.  LI.,  p.  615  ;  Heinricius.  Archiv.  d'Obstetr. 
et  Gynec,  1885. 


Chapter   XV* 

PELVIC  PRESENTATIONS. 

In  pelvic  presentations  the  long  axis  of  the  child  lies  nearly  in 
the  axis  of  the  uterus,  as  in  head  presentations,  but  the  head  is 
directed  upwards  instead  of  downwards.  The  primary  form  of 
pelvic  presentations,  and  that  which  is  more  frequently  observed, 
is  breech  presentation.  In  this  the  attitude  of  the  child  is  generally 
the  same  as  in  vertex  presentation,  all  the  limbs  being  flexed,  and 


Fig.  216. — First,  or  left  sacro-anterior,  position  of  the  breech. 

the  feet  close  to  the  breech,  or  buttocks,  which  form  the  presenting 
part,  {Complete  hreech)  (see  Fig.  216).  It  is  much  more  common, 
however,  than  in  vertex  presentation  for  the  legs  to  be  more  or  less 
extended  on  the  thighs,  because  there  is  not  so  much  space  for  the 
legs  in  addition  to  the  breech  in  the  lower  segment  of  the  uterus  as 
there  is  at  the  fundus.  (See  Fig.  218,  p.  347.)  Sometimes  one  or 
both  thighs  become  extended  on  the  trunk  after  rupture  of  the 
membranes,  or  when  the  bag  of  membranes  is  bulging  through  the 
OS;  either  from  the  gush  of  liquor  amnii,  or  from  active  movement 
of  the  child.     In  this  way  is  developed  out  of  breech  presentation  a 


346 


The  Practice  of   Midwifery. 


presentation  of  one  or  both  knees  (very  rare),  of  one  or  both  feet, 
or  of  a  knee  and  a  foot.  {Incomi^lete  breech).  This  extension  of  thigh 
is  more  likely  to  occur  when  the  breech  does  not  so  fully  occupy 
the  lower  segment  of  the  uterus,  and  when  the  liquor  amnii  is 
relatively  abundant.  Hence  foot  or  knee  presentations,  compared 
with  breech  presentations,  are  relatively  more  frequent  with  pre- 
mature children  and  twins.     When  the  long  axis  of  the  child  is 


Fig.  217. — Foetus  in  utero  with  breech  presentation.     From  a  frozen  section. 
(Modified  from  Waldejer.) 

oblique  in  the  uterus,  the  breech  being  lower,  one  or  both  feet  may 
present  at  the  os  before  rupture  of  the  membranes,  and  the  hands 
may  then  sometimes  be  felt  also.  The  frequency  of  pelvic  presen- 
tation is  estimated  at  from  1  in  60  to  1  in  45  for  mature  children, 
and  at  about  1  in  30  including  all  cases.  Breech  presentations  form 
about  60  or  65  per  cent,  of  all  pelvic  presentations.  The  statistics 
of  Guy's  Hospital  Lying-in  Charity  give — pelvic  presentations  1  in 
38,  breech  presentations  1  in  58,  foot  or  knee  presentations  1  in  121, 


Pelvic  Presentations.  347 

breech  presentations    forming   about    68   per  cent,    of   all   pelvic 
presentations. 

Causation  of  Pelvic  Presentation. — The  causation  may  depend 
on  anything  which  leads  to  the  failure  of  the  forces  which  generally 
produce  head  presentation  (see  p.  140).  Since  the  adaptation  of  the 
child  to  the  shape  of  the  uterus  is  progressively  greater  as  pregnancy 
advances,  pelvic  presentation  is  commoner  with  premature  children. 
It  is  also  commoner  with  multiple  pregnancies,  in  cases  of  placenta 
prsevia,  with  hydrocephalic  children  (see  Fig.  100,  p.  142),  with 
excess  of  liquor  amnii,  with  premature  and  dead  children,  with 


Fig.  218. — Breech  presentation  with  extended  legs. 

tumours  of  the  uterus,  or  with  contraction  of  the  pelvis,  which 
prevents  the  fixation  of  the  head  in  its  normal  position.  In  the 
case  of  dead  children  the  effect  is  chiefly  due  to  the  failure  of  active 
movements,  which  aid  in  adapting  the  position  to  the  shape  of  the 
uterus  (see  p.  142),  but  the  less  relative  specific  gravity  of  the  head 
in  dead  children  has  also  been  considered  to  have  an  influence. 
Pelvic  presentation  is  also  promoted  by  laxity  of  the  walls  of 
the  uterus  or  abdomen,  and  is  therefore  relatively  commoner  in 
multiparse. 

Varieties  of  Breech  Presentation. — There  are  four  positions 
in  breech  presentations,  corresponding  to  the  four  positions  of  the 
vertex.     The  dorso-anterior  positions  are  the  commoner,  like  the 


348  The  Practice  of   Midwifery. 

occipito -anterior  positions  of  the  vertex,  and,  like  them  also, 
differ  in  the  mechanism  of  their  delivery  from  the  dorso-posterior. 
There  is  one  difference,  namely,  that  in  the  case  of  the  breech,  the 
transverse  or  bis-iliac  diameter,  and  not  the  antero-posterior,  is  the 
longest,  and  tends  to  adapt  itself  to  the  longest  diameter  of  the 
pelvis. 

First  or  left  sacro-anterior  (L.  S.  A.). — The  sacrum  looks  toward 
the  left  foramen  ovale ;  the  bis-iliac  diameter  approximates  toward 
the  left  oblique  diameter  of  the  pelvis. 

Second  or  right  sacro-anterior  {R.  S.  A.). — The  sacrum  looks 
toward  the  right  foramen  ovale  ;  the  bis-iliac  diameter  approximates 
toward  the  right  oblique  diameter  of  the  pelvis. 

Third  or  right  sacro-posterior  {R.  S.  P.). —  The  sacrum  looks 
toward  the  right  sacro-iliac  articulation  ;  the  bis-iliac  diameter 
approximates  toward  the  left  oblique  diameter  of  the  pelvis. 

Fourth  or  left  sacro-posterior  (L.  >S'.  P.). — The  sacrum  looks 
toward  the  left  sacro-iliac  articulation ;  the  bis-iliac  diameter 
approximates  toward  the  right  oblique  diameter  of  the  pelvis. 

In  each  of  these  positions,  assuming  the  position  of  the  head  to 
be  adapted  to  that  of  the  trunk,  the  front  and  back  of  the  head 
look  in  the  same  directions  as  in  the  corresponding  positions  of  the 
vertex  or  face.  The  first  position  of  the  breech,  as  of  the  vertex, 
is  the  commonest.  This  is  due  to  the  same  cause.  Owing  to  the 
usual  right  torsion  of  the  uterus  (see  p.  244),  the  large  transverse 
diameter  of  the  uterus  approximates  toward  the  right  oblique 
diameter  of  the  pelvis,  and  the  large  antero-posterior  diameter  of 
the  whole  ovum  most  readily  accommodates  itself  to  this,  the  back 
turning  away  from  the  prominent  lumbo-sacral  curve  of  the  mother, 
and  so  becoming  anterior.  This  frequency  of  the  first  position  in 
breech  presentation  is  a  proof  that  the  position  depends  at  least  as 
much  upon  the  accommodation  of  the  whole  ovum  as  upon  that  of 
the  presenting  part  in  the  i^elvis,  since  the  long  diameter  of  the 
presenting  part  now  occupies  the  left  oblique  diameter  of  the  pelvis, 
which  is  encroached  upon  by  the  rectum  and  sigmoid  flexure. 
Foot  or  knee  presentation  may  arise  out  of  any  of  the  varieties  of 
breech  presentation 

Diagnosis.  —  On  abdominal  examination  the  round,  smooth 
mass  of  the  head  may  be  made  out  at  the  upper  part  of  the  uterus. 
Unless  the  legs  are  extended,  the  fundus  uteri  is  less  broad  than 
usual,  the  lower  segment  broader.  The  foetal  heart  is  heard  most 
distinctly  higher  up  than  in  vertex  presentation,  generally  about 
the  level  of  the  umbilicus.     A  sign  is  given  for  diagnosing  extension 


Pelvic  Presentations. 


349 


of  the  legs  before  the  onset  of  labour,  namely,  that,  in  this  case,  the 
foetal  heart  is  heard  lower  down  than  is  usual  in  pelvic  presentation, 
because  the  breech,  not  being  enlarged  by  the  addition  of  the  legs, 
is  able  to  lie  lower  in  the  pelvis.  The  bag  of  membranes  is  apt  to 
be  large  and  descend  low,  while  the  presenting  i3art  still  remains 
high.     In    foot    presentations    the   bag   is   especially    elongated. 


Fig.  219. 


-Breech  in  pelvis,  left  sacro-anterior  presentation,  seen  from  below. 
Pelvis  in  usual  left  obstetric  position. 


Before  rupture  of  the  membranes,  the  double  contour  of  the 
buttocks  and  the  prominences  along  the  sacrum  may  be  felt ;  and 
sometimes  the  feet  may  be  felt  near  the  breech.  When  the 
membranes  rupture  the  liquor  amnii  escapes  gradually,  but  more 
completely  than  in  vertex  presentations,  the  flow  not  being  stopped 
by  the  action  of  the  head  as  a  ball-valve.  The  pains  after  rupture 
are  apt  to  be  more  frequent  than  in  vertex  presentations,  the 
complete  escape  of  liquor  amnii  allowing  the  uterine  wall  to  come 
into  closer  contact  with  the  foetus.     After  rupture  of  the  membranes 


350 


The   Practice  of   Midwifery. 


in  breech  presentation,  the  os  uteri,  on  vaginal  examination,  is 
found  to  be  occupied  by  two  smooth  elastic  swellings,  the  buttocks, 
on  which  no  tangible  hair,  like  that  on  the  scalp,  can  be  felt.  The 
cleft  between  the  buttocks  can  be  traced  backwards  to  the  coccyx  and 
sacrum — the  spinous  processes  of  the  latter  are  very  characteristic — 
and  in  its  course  can  be  felt  the  anus,  which,  in  a  living  child, 


Fig.  220. — Breech  in  pelvis,  right  sacro-posterior  presentation,  seen  from 
below.     Pelvis  in  usual  left  obstetric  position. 

contracts  on  the  finger  if  an  attempt  be  made  at  introduction.  Thick 
tenacious  meconium  comes  away  on  the  finger,  unlike  that  mixed 
with  liquor  amnii,  which  may  be  expelled  in  head  presentations 
when  the  child  has  undergone  severe  pressure.  The  genitals  may 
also  be  recognised,  and  in  the  male  the  scrotum,  which  becomes 
much  swollen,  is  a  marked  feature.  The  differential  diagnosis  of 
the  breech  from  the  face,  the  only  part  likely  to  be  mistaken  for  it, 
has  been  already  mentioned  (see  p.  338). 

The  knee  is  distinguished  from  the  elbow  by  being  broader,  and 


Pelvic   Presentations. 


351 


having,  besides  the  patella,  two  tuberosities  with  a  slight  depression 
between  them  in  place  of  the  sharp  projection  of  the  olecranon. 
In  case  of  the  slightest  doubt,  after  rupture  of  the  membranes,  the 
diagnosis  should  be  verified  by  bringing  down  the  foot.  The  foot  is 
liable  to  be  confused  with  the  hand  when,  before  rupture  of  the 
membranes,  it  is  only  just  reached  with  the  tip  of  the  finger.  The 
following  are  the  characteristic  differences.  The  toes  form  an  even 
line  and  are  not  very  movable,  while  the  fingers  are  more  irregular 
and  divergent.     The  great  toe  lies  close  to  the  other  toes,  while 


Fig.  221. — Passage  of  breech  under  pubic  arch  by  a  movement  of  lateral 
flexion  (second  position) . 

the  thumb  is  inclined  at  an  angle  to  the  hand,  and  is  opposed  to 
the  other  digits.  The  hand  of  a  living  child  will  often  grasp  the 
examining  finger.  The  most  unmistakable  point  of  all  about  the 
foot  is  the  jDrojection  of  the  heel,  with  the  malleoli  above  it.  This 
is  most  easily  felt  with  absolute  certainty  by  catching  the  foot 
between  two  fingers,  or  between  the  fingers  and  thumb,  as  may 
usually  be  done  without  rupturing  the  membranes  if  they  are  still 
intact,  and  still  more  easily  after  the  escape  of  the  liquor  amnii. 
In  case  of  doubt  whether  foot  or  hand  is  presenting,  as  it  is 
important  to  make  the  diagnosis  early,  it  is  desirable,  if  necessary, 
to  introduce  half,  or-  even  the  whole  hand  into  the  vagina,  in  order 
to  reach  high  enough  to  seize   the  foot   in   this  way.       By    this 


352 


The   Practice  of   Midwifery. 


method  it  is  easy  to  avoid  any  risk  of  mistake  between  the  heel  and 
the  elbow,  which  may  be  confused  if  touched  only  with  the  tip  of 
the  finger.    - 

Mechanism  of  Labour  in  Breech  Presentation. — The  bis-iliac 
diameter  of  the  breech  enters  the  pelvis,  as  already  mentioned, 
nearly  in  one  of  its  oblique  diameters.  There  is  no  movement 
corresponding  to  flexion  in  vertex  presentation.  As  the  breech 
descends  an  internal  rotation  occurs,  similar  to  the  internal  rotation 


Fig.  222. — Passage  of  the  shoulders  in  pelvic  presentation  (first  position). 

of  head  presentations,  the  bis-iliac  diameter  turning  nearly  into 
the  antero-posterior  diameter  at  the  outlet  (see  Fig.  221).  Thus, 
in  the  first  position  of  the  breech,  the  sacrum  turns  from  the  left 
foramen  ovale  toward  the  left  side  of  the  pelvis,  and  the  left  hip 
comes  under  the  pubic  arch.  This  internal  rotation  is  not  generally 
so  complete  as  in  head  presentations,  especially  when  space  is 
ample,  the  breech  being  less  firm  and  incompressible  than  the 
head. 

Corresponding  to  the  extension  in  occipito-anterior  positions  of 
the  vertex  is  a  lateral  flexion  of  the  breech  on  the  trunk,  due  to 
the  inclined  plane  of  the  soft  parts  of  the  pelvic  floor  pushing  the 
forecoming  part   of   the   breech  forward  while  the  trunk  is  held 


Pelvic  Presentations. 


353 


backward  by  the  resistance  of  the  pubes  (see  Fig,  221).  The 
anterior  buttock  thus  comes  under  the  pubic  arch,  while  the 
posterior   buttock  distends   the   perineum.      Combined   with   this 


:S/./ 


sa. 


Fig-.   223. — Diagram   of   mechanism  of  breech  presentations.     (For  general 

scheme    of     diagram,    see    Fig.     159.)        CP   =  antero-posterior 

diameter  of    pelvis  ;    (/)  =  sacrum  ;    1|  =  transverse   diameter   of 

hips  ;  II  =  right  hip  ;  i.,  first  breech,  left  sacro.  anterior  ;  ii.,  rotation 
of  anterior  left  hip  forwards  ;  iii.,  birth  of  hips  by  lateral  flexion,  anterior 
leading;  iv.,  descent  of  shoulders  and  after-coming  head  (for  symbols, 
see  Fig.  159)  ;  v.,  rotation  of  anterior  left  shoulder  to  front  ;  vi.,  birth 
of  shoulders,  left  leading  ;  vii.,  rotation  forwards  of  occiput  of  after- 
coming  head;  viii.,  further  rotation  of  occiput  to  front ;  ix.,  birth  of  head 
flexed  with  occiput  anterior. 


lateral  flexion  is  a  slight  posterior  flexion  of  the  breech  on  the 
trunk  in  dorso-anterior  positions,  and  anterior  flexion  in  dorso- 
posterior  positions.  These  are  analogous  to  the  lateral  flexion 
of  the  head  toward  the  anterior  shoulder  near  the  outlet  of  the 
M.  23 


354 


The   Practice  of   Midwifery. 


genital  canal  in  head  presentations,  and.  are  due  to  a  similar  cause. 
The  anterior  buttock  is  the  first  to  appear  at  the  vulva,  and 
the  first  to  be  delivered,  provided  that  the  perineum  is  intact 
(see  Fig.  221).  When  the  perineum  is  deficient,  the  posterior 
buttock  may  be  the  first  to  escape.^ 

After  the  buttocks  have  escaped  from  the  vulva,  there  is  a  slight 
movement  of  restitution  in  the  reverse  direction  to  the  internal 
rotation,  the  breech  returning  toward  the  oblique  diameter  which 
it  originally  occupied,  so  as  to  accommodate  itself  to  the  position 
of   the   shoulders,  which  are   entering  the  pelvis  in  the  oblique 

diameter.  This  is  not  so 
marked  as  in  head  presenta- 
tion. The  feet  escape  close  to 
the  buttocks,  unless  the  legs 
are  extended,  the  thighs  are 
delivered  soon  after,  and  the 
abdomen  descends.  Provided 
no  traction  has  been  made 
upon  the  child,  the  arms 
generally  emerge,  folded  upon 
the  chest,  before  the  shoulders 
As  the  shoulders  approach  the 
outlet,  the  bis-acromial  dia- 
meter, like  the  bis-iliac,  turns 
nearly  into  the  antero-pos- 
terior  diameter  of  the  outlet 
(Fig.  224). 

The  head  enters  the  pelvis 
in  the  right  oblique  or  nearly 
in  the  transverse  diameter, 
and  is  maintained  in  a  position  of  flexion  by  the  pressure  of  the 
uterus  upon  it  so  long  as  no  traction  is  made  upon  the  child. 
As  in  head-first  deliveries,  the  long  diameter  of  the  head  turns 
nearly  into  the  antero-posterior  diameter  of  the  outlet,  so  that 
the  occiput  escapes  under  the  pubic  arch  (Fig.  225).  As  soon  as 
the  head  has  been  expelled  out  of  the  powerfully  contracting 
body  of  the  uterus  into  the  distended  cervix  and  vagina,  the 
expulsive  force  necessarily  acts  at  a  great  disadvantage  (see 
Fig.  225,  p.  354).  The  only  force  which  then  comes  into  play  is 
that  of  the  auxiliary  muscles  and  the    feeble  contractile  powers  of 


Fig.  22i. — Passage  of  the  shoulders  in 
pelvic  presentation,  one  arm  extended 
(second  position). 


1  It  is  sometimes  stated  that  the  rule  is  for  the  posterior  buttock  to  be  born  first, 
but  this  only  occurs  when  there  is  deficiency  of  the  posterior  wall  of  the  genital  canal 
from  former  rupture  of  the  perineum. 


Pelvic  Presentations. 


355 


the  vagina  and  cervix.  Hence  the  head  is  apt  to  be  delayed  at 
this  stage,  and  the  foetus  to  die  from  asphyxia.  But  generally 
expulsion  is  effected  chiefly  by  the  action  of  the  abdominal  muscles, 
strongly  stimulated  by  the  presence  of  the  large  hard  head  in  the 
vagina.  If  delivery  thus  takes  place  naturally,  flexion  of  the  chin 
is  maintained  to  the  last,  the  chin  and  face  emerging  first,  and 
the  occiput  last.  In  the  second  position  of  the  breech,  the 
mechanism  is  precisely  tbe  same 
as  in  the  first,  right  and  left 
being  interchanged. 

Mechanism    in    Dorso-pos- 
terior  Positions  of  the  Breech. 

—  Suppose  the  child  to  be  in  the 
third  position  of  the  breech,  the 
sacrum  looking  toward  the  right 
sacro-iliac  synchondrosis.  The 
sacrum  in  tbis  case  rotates 
forward  instead  of  backward,  so 
that  the  right  or  anterior  buttock 
rotates  forward  under  the  pubic 
arch.  The  buttocks  are  then 
delivered  by  lateral  flexion  in 
the  same  way  as  in  sacro-anterior 
positions.  If  the  bis-iliac  dia- 
meter has  rotated  completely 
into  the  antero-posfcerior  dia- 
meter of  the  j)elvis,  the  external 

rotation  of  the  breech  is  generally  continued  on  in  the  same 
direction  as  the  internal  rotation,  and  not  reversed.  The  bis- 
acromial  diameter  of  the  shoulders  thus  enters  the  brim  in  the 
right  oblique  diameter  instead  of  following  the  bis-iliac  in  the  left 
oblique.  The  long  diameter  of  the  head  enters  the  brim  with  the 
occiput  somewhat  forward,  and  labour  is  completed  as  in  the 
second  position  of  the  breech.  The  only  explanation  which  can  be 
given  for  this  is  the  general  tendency  of  the  spine  of  the  child  to 
rotate  forward  away  from  the  spine  of  the  mother.  Sometimes, 
however,  especially  if  the  internal  rotation  of  the  breech  has  been 
incomplete,  there  is  an  external  rotation  in  the  reverse  direction, 
and  the  bis-acromial  diameter  enters  the  brim  in  the  left  oblique, 
rotating  into  the  antero-posterior,  or  nearly  so,  as  it  descends. 
The  head  then  enters  the  brim  with  the  occiput  directed  laterally 
or  a  little   backward.     As  it  descends  the  occiput  almost  always 

23—2 


Fig.  225.— Descent  of  the  head. 


356 


The  Practice  of  Midwifery. 


^1.  ^.s.a 


Fig.  226. — Diagram  of  mechanism  of   labour  in  foot  or  knee  presentation. 

1|-^  =  transverse  diameter  of  hips  with  foot  or  knee  presenting  (for 

other  symbols,  vide  Figs.  159,  and  223).  The  diagram  shows  the  rotation 
of  the  posterior  hip  to  the  front,  in  this  case  the  right  hip  and  the 
accompanying  rotation  of  the  shoulders  and  head. 


Pelvic  Presentations.  357 

rotates  forwards  under  the  pubic  arch.  The  cause  of  this  move- 
ment is  that  the  neck,  which  is  attached  to  the  posterior  part  of  the 
head,  meeting  the  resistance  of  the  inchned  plane  of  the  pelvic 
floor,  turns  away  from  it  into  the  free  space  under  the  pubic  arch. 


Irregularities  of  Mechanism. — In  rare  cases  of  dorso-posterior 
position,  the  occiput  remains  j)osterior,  turning  somewhat  toward 
the  hollow  of  the  sacrum.  This  is  most  likely  to  happen  when 
space  is  ample,  so  that  little  or  no  internal  rotation  of  the  buttocks 
or  shoulders  occurs,  and  the  back  continues  to  look  toward  the 
sacrum  during  the  passage  of  the  trunk.  The  head  may  then 
still  be  delivered  in  a  position  of  flexion,  the  chin  and  face  first 
escaping  under  the  pubes,  and  the  occiput  finally  passing  over 
the  perineum.  Cases  have  been  recorded  of  a  much  more  rare 
occurrence,  namely,  that  the  head  becomes  extended  into  a  posi- 
tion like  that  of  face  presentation,  the  face  looking  upward  toward 
the  abdomen,  while  the  occiput  is  pressed  down  upon  the  back. 
The  occiput  is  then  said  to  emerge  first  over  the  perineum,  while 
the  chin  is  delayed  behind  the  pubes,  and  the  face  is  born  last. 
But,  in  such  a  position,  the  head  is  arrested,  unless  very  small  in 
proportion  to  the  pelvis. 

Mechanism  in  Foot  or  Knee  Presentation. — If  one  thigh 
only  is  extended,  the  extended  thigh  forms  the  most  advanced 
part  of  the  foetus,  is  the  first  to  meet  the  resistance  of  the  inclined 
plane  of  the  pelvic  floor,  and  therefore,  according  to  the  universal 
rule,  turns  forward  away  from  the  resistance  into  the  free  space 
under  the  pubic  arch.  Therefore  the  buttock  corresponding  to 
the  extended  thigh  becomes  eventually  anterior.  The  delivery  of 
the  body  and  head  is  the  same  as  in  breech  presentations  (Fig.  226). 

Moulding     of    the     Child    in    Pelvic    Presentation.  —  The 

cedematous  swelling,  corresponding  to  the  caput  succedaneum, 
occupies  mainly  the  anterior  buttock,  and  includes  the  genitals, 
especially  the  scrotum  in  a  male.  The  absence  of  any  caput 
succedaneum  on  the  head  is  notable.  The  shape  of  the  head 
is  little  altered,  bat  it  becomes  somewhat  more  rounded  than  the 
head  before  moulding,  the  vertical,  or  cervico-l^regmatic  diameter 
being  relatively  increased.  This  is  due  to  the  pressure  of  the 
genital  canal  on  the  front,  back,  and  sides  being  more  continuous 
than  the  uterine  pressure  on  the  top  of  the  head. 


358  The   Practice  of   Midwifery. 

Prognosis. — The  prognosis  is  slightly  more  unfavourable  for 
the  mother  than  in  vertex  presentations,  since  artij&cial  delivery 
of  the  child  has  not  infrequently  to  be  undertaken ;  Hecker/  taking 
all  cases,  estimates  the  maternal  mortality  at  2'07  per  cent.  The 
first  stage  of  labour  is  generally  more  tedious,  since  the  breech 
is  not  so  well  shaped  a  dilator  as  the  head,  and,  from  its  softness, 
does  not  stimulate  the  nerves  of  the  cervix  so  powerfull}^  The 
passage  of  the  head  is  also  apt  to  be  delayed,  the  breech  not  being 
large  enough  to  dilate  the  passages  sufficiently  to  allow  it  to  pass 
with  ease,  and  tearing  of  the  soft  parts  is  likely  to  ensue.  If  one 
foot  or  knee  present,  and,  still  more,  if  both  do  so,  the  likelihood 
of  delay  is  greater,  the  fore-coming  part  of  the  foetus  being  then 
a  more  inefficient  dilator  than  the  breech. 

In  this  way  arises  the  great  danger  to  the  child's  life  in  pelvic 
presentations.  One  cause  of  this  is  pressure  on  the  funis.  This 
begins  in  some  measure  as  soon  as  the  umbilicus  is  entering  the 
brim,  that  is,  when  the  buttocks  are  passing  the  vulva  (see  Fig. 
221,  p.  351),  but  is  much  greater  when  the  trunk  is  born,  and  the 
funis  is  compressed  between  the  hard  head  and  the  pelvis.  A  still 
more  important  cause  is,  that  by  the  shrinking  of  the  uterus  on  the 
expulsion  of  the  main  part  of  the  bulk  of  the  foetus  the  placental 
circulation  is  more  or  less  arrested  by  compression  of  the  uterine 
arteries,  and  the  j)lacenta  may  even  be  partially  detached.  This 
is  especially  the  case  when  the  head  is  completely  expelled  out 
of  the  body  of  the  uterus  into  the  cervix  and  vagina  (see  Fig.  225, 
p.  355). 

Premature  attempts  at  respiration  are  also  very  likely  to  occur 
leading  to  the  aspiration  of  mucus  or  liquor  amnii  into  the  child's 
air  passages.^  A  comparatively  short  delay  at  this  stage  is  therefore 
inevitably  fatal  to  the  child. 

Spencer^  has  shown  that  injuries  to  the  thoracic  and  abdominal 
viscera  are  very  common  in  breech  presentations,  while  injuries 
to  the  sternomastoid  muscles  and  the  nerves  in  the  neck  are  very 
liable  to  follow  forcible  traction  on  the  after-coming  head. 

The  proportion  of  children  still-born  varies  very  much  according 
to  the  skill  of  the  accoucheur,  and  therefore  is  very  differently 
estimated  by  different  authors.  Churchill  gives  the  mortality  as 
1  in  3^,  Von  Winckel  1  in  5,  Dubois  as  1  in  11.  The  statistics  of 
the  Guy's  Hospital  Lying-in  Charity,  where  the  labours  are  attended 
by  students,  and  where  the  child  is  often  born  before  the  arrival 
of  the  accoucheur,  give  a  still  higher  mortality  than  that  estimated 

1  Hecker,  loc.  cit.,  p.  255. 

2  Spencer,  Trans.  Obst.  Soc.  London,  1891,  Vol.  XXXIII. ,  p.  203. 


Pelvic   Presentations.  359 

by  Churchill,  namely,  1  in  3'0  for  breech  presentation,  and  1  in 
2" 3  for  foot  or  knee  presentation,  out  of  49,145  deliveries. 

In  the  years  1896—1906  at  the  Basle  KliniV  among  10,842 
births  there  were  368  breech  presentations.  Of  the  mothers 
8,  or  2'17  per  cent.,  died,  and  28,  or  7'6  j)er  cent.,  of  the  children. 
The  foetal  mortality  among  the  primiparse  was  1  in  7,  and  among 
the  multiparaB  1  in  12. 

Management  of  Pelvic  Presentations. — In  all  cases  where  a 
breech  presentation  is  recognised  before  the  onset  of  labour  an 
attempt  should  be  made  to  convert  it  into  a  vertex  presentation  by 
the  performance  of  external  cephalic  version.  Pollock^  has  shown 
that  this  procedure  is  rendered  much  easier  and  more  certain  if 
the  patient  be  placed  in  the  Trendelenburg  position.  The  risks  to 
the  mother  and  the  child  are  much  less  in  a  vertex  than  in  a 
breech  presentation,  and  even  if  the  attempt  at  version  fails  no 
harm  ensues. 

The  first  and  most  essential  point  in  the  management  of  pelvic 
presentations  during  labour  is  to  abstain  from  premature  interfer- 
ence with  nature.  In  the  first  instance  the  membranes  must  be 
kept  intact  as  long  as  possible,  in  order  to  get  the  greatest  possible 
dilatation  of  the  soft  parts  by  their  means,  since  the  breech  forms 
an  inefficient  dilator  to  prepare  the  way  for  the  larger- sized  head 
which  has  to  follow  it.  In  presentation  of  one  or  both  feet,  this 
necessity  is  still  greater,  since  the  half-breech,  or  both  legs  together, 
form  a  still  worse  dilator  than  the  breech. 

After  rupture  of  the  membranes,  it  is  still  necessary  to  leave 
matters  to  nature  as  long  as  possible.  The  midwife  or  inex- 
perienced student  may  be  tempted  by  the  facility  for  traction 
which  is  offered  by  the  body  or  legs  of  the  child,  especially  if  the 
labour  proves  tedious.  But  if  any  traction  is  made  prematurely, 
two  evil  results  follow.  First,  the  arms,  instead  of  remaining 
folded  on  the  breast  and  slipping  out  before  the  head,  are  retarded 
by  friction.  They  then  slip  up  by  the  sides  of  the  head,  and 
become  jammed  with  the  head  in  the  pelvis,  thus  frequently 
causing  the  loss  of  the  child's  life.  Secondly,  the  tractile  force 
being  transmitted  through  the  neck,  the  anterior  arm  of  the  head- 
lever  is  the  longest ;  the  resistance  which  it  meets  has  therefore 
the  mechanical  advantage  over  that  experienced  by  the  posterior 
or  occipital  arm,  and  the  head  becomes  extended.  In  this  way  the 
maximum  vertico-mental   diameter   of  the  head   may  be   thrown 

1  iHiaelowitz,  Inauf,'.  Diss.,  Basle,  IDOf). 

2  Pollock,  Trans.  Obst.  Soc.  London,  IDOfJ,  Vol.  XLVIH.,  p.  iH'J 


36o 


The  Practice  of   Midwifery. 


across  the  pelvic  brim,  or  nearly  so,  and  find  the  space  insufficient 
for  its  passage. 

The  first  pressure  upon  the  funis,  and  consequent  risk  to  the 
child,  begins  when  the  umbilicus  enters  the  pelvic  brim,  or  about 
the  time  when  the  breech  is  passing  the  vulva,  but  it  becomes 
much'greater  when  the  child  is  born  as  far  as  the  umbilicus.  It  is 
just  before  this  time  that  the  first  duty  of  the  attendant  commences. 
As  soon  as  he  can  easily  reach  the  umbilicus  by  passing  a  finger 


Fig.  227. — Manual  extraction  of  head  through  the  outlet  of  soft  parts. 


just  within  the  vagina,  he  should  draw  a  loop  of  the  cord  gently 
downward.  The  object  of  this  is  twofold — first,  to  prevent  the 
cord  undergoing  any  longitudinal  stretching  as  the  child  advances, 
and  consequent  interference  with  the  circulation  through  its  spiral 
vessels ;  secondly,  to  enable  him  to  watch  the  foetal  pulsations  in 
the  cord,  and  so  judge  of  any  danger  to  the  foetus.  The  loop 
of  cord  should  also  be  guided  to  that  part  of  the  pelvis  where 
there  is  most  room  for  it,  generally  opposite  the  sacro-iliac 
synchondrosis. 

From  this  time  the  delivery  may  be  accelerated  so  far  as  this 


Pelvic  Presentations.  361 

can  be  done  by  encouraging  the  patient  to  bear  down,  and  by 
pressure  from  above  on  the  fundus.  But  still  there  must  be  no 
further  interference,  unless  there  are  signs  that  the  child  is  in 
imminent  peril.  The  most  significant  of  these  are  inspiratory 
efYorts,  made  while  the  mouth  and  nose  are  still  retained  within 
the  passages.  These  are  evidence  that  the  child  is  becoming 
suffocated.  Failure,  or  great  retardation,  of  the  pulsation  of  the 
funis  is  also  an  indication  that  it  is  necessary  to  have  recourse  to 
extraction. 

As  the  breech  and  body  of  the  child  are  passing  the  vulva  the 
physician  should,  with  his  right  hand,  support  the  body,  and  carry 
it  forward  between  the  mother's  thighs  towards  her  abdomen,  thus 
aiding  the  lateral  flexion  of  its  body  (see  p.  351).  At  the  same 
time  he  should  assist  the  expulsion  by  pressing  with  his  left  hand 
upon  the  fundus  uteri.  Such  external  pressure  is  of  special  value, 
because,  while  aiding  the  expulsive  force,  it  also  promotes  the 
flexion  of  the  head,  and  tends  to  keep  the  arms  in  their  natural 
position  across  the  chest.  In  most  cases  it  will  prevent  the  necessity 
for  having  recourse  to  artificial  extraction.  After  the  arms  have 
appeared,  and  when  the  head  is  reaching  the  vulva,  it  is  better  to 
hand  over  to  the  nurse,  or  other  assistant,  the  duty  of  pressing 
upon  the  fundus,  and  spread  out  the  left  hand  behind  the  perineum 
in  front  of  the  sacro-sciatic  ligaments,  in  the  same  position  as  that 
described  at  p.  303  for  the  case  of  the  fore-coming  head.  By 
pressure  in  this  situation,  the  finger  and  thumb  keep  the  head 
forward  under  the  pabic  arch,  and  so  tend  to  avert  rupture  of  the 
perineum,  while  at  the  same  time,  by  pressure  upon  the  forehead 
at  the  final  stage  of  expulsion,  they  may  assist  the  exit  of  the  head. 

Extraction  of  the  Head. — "When  the  after-coming  head  is  expelled 
out  of  the  strong  contractile  body  of  the  uterus  into  the  dilated 
cervix  and  vagina  (see  Fig.  225),  the  natural  forces  act  upon  it  at  a 
very  great  disadvantage.  For  the  only  expelling  forces  are  now 
the  weak  contractile  powers  of  the  cervix  and  vagina  and  the  action 
of  the  auxiliary  muscles.  Hence  at  this  stage  sufficient  delay  to 
cause  the  death  of  the  child  is  apt  to  be  produced,  if  the  case  is  left 
to  nature.  As  soon,  therefore,  as  the  arms  have  escaped,  the  head 
should  be  extracted  if  it  does  not  immediately  follow. 

At  this  stage  the  resistance  is  due  only  to  the  soft  parts  of  the 
vaginal  and  vulval  outlet,  and  is  usually  not  considerable.  There 
is,  however,  one  mechanical  difficulty  in  artificial  extraction.  The 
force  of  traction,  acting  through  the  spinal  column,  is  applied  to  the 
head  at  a  point  nearer  to  its  posterior  than  to  its  anterior  extremity. 
Hence,  if  traction  is  made  in  the  axis  of  that  plane  of  the  genital 


362 


The   Practice  of   Midwifery. 


canal  in  which  the  centre  of  the  head  lies  (see  Fig.  22,  p.  21),"  the 
occiput  is  drawn  down  more  than  the  forehead,  the  head  becomes 
extended,  a  larger  diameter  of  it  is  thrown  across  the  genital  canal, 
and  in  consequence  the  resistance  is  greatly  increased,  and  the 
perineum  is  endangered. 

Hence  the  object  to  be  attained  is  to  make  traction  in  such  a 
way  as  to  avoid  causing  extension,  and  secure  the  descent  of  the 
chin.  There  are  three  means  available  for  attaining  this  end  :  the 
application  of  forceps,  the  so-called  Prague  method  of  delivery,  and 


Fig.  228. — Shoulder  and  jaw  traction.     (Mauriceau-Smellie-Veit  Method.) 


traction  on  the  shoulders  of  the  child  with  the  introduction  of  the 
finger  into  the  mouth  of  the  child  so  as  to  promote  flexion  of  the 
head,  shoulder  traction  with  a  jaw  hold. 

The  application  of  forceps  is  undoubtedly  the  safest  and  one  of  the 
most  effective  methods  of  delivering  the  after-coming  head,  and  in 
all  cases  of  breech  presentation  they  should  be  ready  at  hand  in 
case  they  may  be  wanted.  If,  however,  the  forceps  are  not 
immediately  available,  one  of  the  two  other  methods  may  be 
employed.  In  applying  the  Prague  method  the  j^roceeding  is  as 
follows  : — Wrap  the  legs  and  feet  of  the  child  in  a  napkin  and  seize 
them  with  the  right  hand.     Hook  the  left  hand  over  the  back  of  the 


Pelvic   Presentations.  363 

neck,  as  shown  in  Fig.  227.  Then  carry  the  legs  forward  in  a 
direction  almost,  but  not  quite,  at  right  angles  to  the  pubes,  as 
indicated  in  the  figure.  Make  traction  in  this  direction  with  the 
right  hand.  Aid  the  traction  with  the  left  hand,  but  use  this  hand 
chiefly  to  steady  the  head,  and  prevent  its  escaping  with  too  sudden 
a  jerk. 

The  exj^lanation  of  the  success  of  this  method  is  as  follows  :  The 
forward  direction  of  the  traction  causes  a  pressure  of  the  pubes 
against  the  occiput.  This  force,  combined  with  the  component  of 
the  tractile  force  resolved  perpendicularly  to  the  pubes,  and  acting 
through  the  condyles,  forms  a  "couple,"  or  pair  of  equal  and 
opposite  forces  not  acting  in  the  same  straight  line,  which  tends  to 
cause  descent  of  the  chin  and  ascent  of  the  occiput.  This  method 
is  equally  applicable  when  the  occiput  looks  backwards,  the  feet  of 
the  child  being  carried  up  over  the  mother's  abdomen  and  traction 
being  made  with  the  other  hand  on  the  shoulders.  In  this  case  the 
head  is  born  with  the  occiput  leading,  the  face  emerging  last,  and,  as 
a  result,  the  perineum  is  very  likely  to  be  torn. 

In  a  parous  woman  this  method  will  almost  always  instantly 
release  the  head  when  once  it  has  reached  the  pelvic  floor.  The 
only  difficulty  likely  to  occur  is  in  a  primipara,  to  whom,  with 
a  forecoming  head,  rupture  of  the  perineum  would  be  likely  to 
occur.  In  such  a  case  a  considerable  amount  of  force  may  have  to 
be  employed,  and  this  is  likely  to  lead  not  only  to  rupture  of  the 
mother's  perineum,  but  also  to  injury  to  the  tissues  of  the  child's 
neck,  especially  the  sternomastoid  muscles.  In  these  circumstances, 
while  an  assistant,  if  one  be  available,  makes  traction  on  the  child's 
legs,  pressure  should  be  made  on  the  fundus  uteri  with  one  hand, 
and  the  other  should  be  applied  just  in  front  of  the  sacro-sciatic 
ligaments  in  an  attempt  to  squeeze  the  head  out  through  the 
vulva.  In  a  really  difficult  case,  however,  where  there  is  marked 
rigidity  of  the  soft  parts  or  possibly  some  contraction  of  the  bony 
outlet  of  the  pelvis,  shoulder  traction  with  a  jaw  grip  must  be 
resorted  to.  In  this,  the  so-called  Mauriceau-Smellie-Veit  manoeuvre, 
the  index  finger  of  the  left  hand  is  passed  into  the  vagina  and 
placed  far  back  on  the  edge  of  the  inferior  maxilla  of  the  fcetus. 
At  the  same  time  the  first  and  second  fingers  of  the  right  hand  are 
applied  to  the  child's  shoulders.  Traction  is  then  made  on  the 
shoulders,  aided  by  the  pressure  of  an  assistant's  hand  on  the  fundus 
of  the  uterus,  while  the  finger  in  the  mouth  aids  in  the  traction 
and  at  the  same  time  keeps  the  head  in  a  flexed  position.  This  is 
a  very  effective  manoeuvre  both  in  causing  flexion,  and  in  adding 
to  the  tractile  force  without  increasing  the  tension  upon  the  neck. 


364  The  Practice  of   Midwifery. 

but  it  is  rarely  required  to  overcome  resistance  due  only  to  the  soft 
parts.  An  alternative  and  very  useful  method  is  the  introduction 
of  the  index  finger  of  the  left  hand  into  the  mouth  of  the  foetus  to 
produce  flexion  while  traction  is  made  on  its  legs  with  the  right 
hand,  and  the  descent  of  the  head  aided,  if  necessary,  by  pressure 
made  on  it  through  the  abdomen  by  an  assistant. 


Chapter   XVI. 

MULTIPLE  PREGNANCY. 

By  multiple  pregnancy  is  meant  the  simultaneous  development 
of  more  than  one  embryo.  The  case  of  chief  practical  importance 
is  that  of  twin  pregnancy,  which  occurs,  taking  an  average  for 
different  countries,  about  once  in  eighty  cases.  Triplets  are  found 
only  about  once  in  6,400  pregnancies  (80^).^  It  is  extremely  rare  to 
find  a  greater  number  of  embryos  than  three,  quadruplets 
occurring  about  once  in  512,000  births  (80^),  and  quintuplets,  of 
which  there  are  a  few  on  record,  once  in  40,960,000  (80*).  In  1888 
Vassalli  recorded  a  case  in  which  six  foetuses,  two  female  and  four 
male,  were  expelled  at  the  fourth  month  of  pregnancy. 

Causation. — The  proportion  of  twin  pregnancies  varies  in 
different  countries,  and  it  may  be  inferred  that  the  variation 
depends  upon  difference  of  race.  On  the  whole,  multiple  pregnancy 
appears  to  be  commonest  among  the  most  fertile  races.  Thus  in 
Ireland  the  proportion  is  about  1  in  60,  in  England  only  about 
1  in  110.  The  highest  rate  is  met  with  in  Dublin,  1  in  57,  and 
the  lowest  in  Naples,  1  in  158.  Individual  women  occasionally 
show  a  tendency  to  rej^eated  twin  pregnancy,  and  there  is  evidence 
that  this  tendency  may  be  hereditary,  although  this  does  not  appear 
to  apply  to  uniovular  twins.  Such  constitutional  or  hereditary 
tendency  shows  itself,  as  a  rule,  on  the  mother's  side,  but  there  is 
some  reason  for  believing  that  the  father  may  also  have  an 
influence,  for  an  unusual  number  of  twin  pregnancies  have  some- 
times occurred  in  the  families  of  brothers,  or  in  those  of  the  same 
husband  by  different  wives.  Von  WinckeP  has  recorded  a  case  in 
which  the  paternal  influence  was  shown  in  three  generations,  twins 
being  born  six  times  in  nine  births.  According  to  the  statistics 
collected  by  Matthews  Duncan,^  the  tendency  to  production  of 
twins  increases  with  successive  pregnancies,  with  the  exception  of 
the  first  pregnancy,  at  which  it  is  greatest  of  all ;  and  the  later  in 
life  women  are  married,  the  more  likely  are  twins  to  be  born  at  the 

'  Hellin,  Die  Ursache  der  Multiparitiit,  Mlinchen,  1895. 

2  Strassmann  ;  Von    Winckel,   Handbuch   der  Geburtshiilfe,  1904,  Vol.  I.,    Part  2. 
p.  743. 
8  Matthews  Duncan,  On  Fecundity,  Fertility,  and  Sterility.  Edinburgh,  1866. 


366 


The  Practice  of   Midwifery. 


first  delivery.  It  has  generally  been  considered  that  the  tendency 
to  produce  twins  is  associated  with  unusual  fertility  and  an  atavistic 
tendency,  but  Matthews  Duncan,^  from  observations  on  animals, 
infers  that  the  birth  of  twins  may  be  a  stage  on  the  way  toward 
sterility. 

Twin  pregnancy  may  be  either  of  the  binovular  or  the  uniovular 
variety. 

Binovular  Twins. — Two  or  more  ova  may   become  fertilised 
at  the  same  time,  and  an  excess  of  Graafian  follicles  in  the  ovary 


Fig-.  229. — Twins  in  utero,  both  presenting  by  vertex. 

appears  to  predispose  to  this.  These  may  proceed  either  from 
the  same  or  different  ovaries,  and,  in  some  cases,  may  both 
escape  from  the  same  Graafian  follicle.  The  possibility  of  two  ova 
being  thus  fertilised  at  the  same  time  is  proved  by  the  finding,  in 
some  cases,  of  two  corpora  lutea  equally  developed,  and  by  the 
occasional  occurrence  of  simultaneous  pregnancy  on  the  two  sides 
of  a  double  uterus,  also  by  that  of  twin  pregnancy  with  one  foetus 
in  the  uterus  and  one  extra-uterine.  It  is  probable  that  both  ova 
may  be  fertilised  at  the  same  coitus,  but  this  is  not  always  the 
case.     This  occurrence  is  called  swperfecundation,  and  is  supported 

1  Matthews  Duncan,  On  Sterility  in  Woman,  London,  ISS-l. 


Multiple   Pregnancy.  367 

by  the  fact  that  sometimes  children  of  different  colours  have  been 
born,  one  white  and  one  mulatto,  or  one  mulatto  and  one  negro.  It 
must  be  remembered,  however,  that  of  the  two  children  of  a  negress 
by  a  white  father  one  may  be  quite  dark  at  the  time  of  birth  and 
the  other  quite  light,  and  to  prove  superfecundation  in  the  human 
subject  it  would  be  necessary  for  two  foetuses  to  be  born  of  the 
same  mother  presenting  the  definite  characteristics  of  two  different 
races.  In  the  case  of  animals,  it  is  known  that  different  foetuses  in 
the  same  litter  may  have  different  fathers. 

When  the  twins  arise  from  two  different  ova,  each  will  be  enclosed 
in  its  own  amnion  and  chorion,  and  generally,  in  the  first  instance, 
its  own  decidua  reflexa,  although  if  the  two  foetuses  are  implanted 
very  close  to  one  another  in  the  uterus  only  one  decidua  reflexa 
may  be  formed.  When  the  growing  ova  come  into  contact,  and  a 
partition  between  them  is  formed  by  the  union  of  their  walls,  the 
decidua  reflexa  may  soon  become  thinned  and  lost  in  the  partition. 
Only  four  layers,  instead  of  six,  are  then  traceable  in  the  partition, 
two  of  chorion  and  two  of  amnion.  The  placentae  may  be  entirely 
separate,  or  they  may  be  joined  at  their  borders  or  united  by  a 
membranous  portion,  but  there  is  no  vascular  communication 
between  them.  From  the  fact  that  two  distinct  bags  of  membranes 
are  most  frequently  found  (in  about  85  per  cent,  of  all  cases),  it 
appears  that  this  variety  of  twin  pregnancy  is  the  commonest. 

Uniovular  Twins. — An  ovum  may  have  a  double  germinal 
vesicle,  and  an  embryo  be  developed  from  each.  Such  ova  are  met 
with  not  uncommonly.  In  this  case  the  placenta  and  chorion  are 
common  to  the  two,  but  the  amniotic  sacs  are  separate.  Tlie 
septum  between  them  may,  however,  break  down  or  be  absorbed, 
and  the  embryos  may  thus  come  to  be  contained  in  a  single  bag 
of  membranes.  In  this  variety,  there  is  frequently  more  or  less 
vascular  communication  in  the  placenta  between  the  two  embryos. 
A  single  chorionic  cavity  occurs  in  about  14  to  15*5  per  cent,  of 
twin  pregnancies. 

When  we  remember  that  this  view  necessitates  the  extrusion  of 
two  polar  bodies,  the  formation  of  two  female  j)ronuclei,  and  the 
entrance  of  two  spermatozoa,  it  is  obvious  that  it  presents  many 
difficulties,  and  they  are  not  lessened  by  the  fact  that  the  develop- 
ment of  two  blastodermic  vesicles  may  lead  to  the  formation  of  two 
chorions,  and  it  is  necessary  to  imagine  that  these  coalesce  so  as  to 
give  rise  to  the  single  chorion  existing  with  uniovular  twins.  It  is 
much  simpler  and  more  probable  to  hold  the  view  that  a  single 
blastodermic  vesicle  may  give  rise  to  two  embryonic  areas.      If  the 


368 


The   Practice  of   Midwifery. 


two  embryonic  areas  remain  completely  separate  uniovular  twins 
develop,  whereas  if  they  are  in  close  proximity  and  become  united 
they  give  rise  to  one  or  other  of  the  varieties  of  double  monsters. 
In  the  latter  case  only  a  single  amniotic  cavity  is  developed  from 
the  first.  It  is  possible  that  the  same  may  be  the  case  in  some 
instances,  when  the  embryos  are  completely  separated,  especially  if 


Fig.  230. — Diagrams  of  the  arrangement  of  the  placentae  and  membranes  with  unioYular 
twins  ;  a,  with  double  amnion  ;  h,  with  single  amnion. 

I- ' •  =  decidua. 

=  separate  amnions. 

=  single  amnion. 

^^  =  placenta,. 

'ft^^f^f&Z  =  communicating  areas  of  placentae, 
(From  V.  Winckel,  Handb.  der  Geburtshlilfe,  Vol.  I.,  Pt.  II,,  Plate  V.) 

the  separation  does  not  extend  fully  to  the  abdominal  pedicle.  In 
this  variety  also  there  is  a  single  placenta,  and  generally  vascular 
communication  between  the  embryos.  In  some  cases  the  funis  is 
single  near  its  placental  insertion,  bat  contains  a  double  set  of 
vessels,  and  bifurcates  on  aj)proaching  the  foetuses,  thus  indicating 
that  the  cleavage  of  the  area  germinativa  did  not  extend  throughout 
the  abdominal  pedicle,   and  some  authorities  believe  that,  in  all 


Multiple   Pregnancy. 


3^9 


such  cases,  an  amniotic  septum  existed  originally,  but  has  been 
broken  down.  But  it  is  uncertain,  when  there  is  a  common  chorion 
and  separate  amniotic  cavities,  whether  the  twins  originated  from  a 
double  yolk,  or  from  cleavage  of  the  area  germinativa.  Sobotta 
believes  that  the  latter  is  always  the  explanation,  considering  that 
it  is  impossible  for  a  second  spermatozoon  to  enter  the  ovum  and 
unite  with  a  second  female  pronucleus.^ 

In  only  about  0*25   per  cent.   (1  in  389)  of  all  cases  the  twins 
are  found  in  a  single  amniotic  cavity   (Ahlfeld).^     It  is  said  that 
twins  contained  in  the  same  amniotic  cavity  show,  in  after-life,  a 
much  closer  resemblance   to 
each    other     than     ordinary 
twins. 

Uniovular  twins  are  more 
often  of  the  male  than  of 
the  female  sex,  the  mothers 
are  apt  to  be  young  or  rela- 
tively old,  death  of  the  foetus 
or  malformations  are  com- 
moner than  with  binovular 
tv/ins,  and  heredity  appears 
to  play  no  part  in  their  pro- 
duction. 

In  triplets,  it  appears  that 
most  frequently  two  are 
developed  from  the  same 
ovum,  and  the  third  from  a 
second  ovum. 


Fig.  231. — Acardiac,  acephalic  foetus. 


Acardiac  Monsters.  — 
When  two  embryos  are  con- 
tained within  a  common  chorion,  the  abdominal' pedicle  of  one  may 
remain  partially  blended  with,  or  be  in  close  vicinity  to,  the 
abdominal  pedicle  of  the  other.  In  such  twins  developed  from  a 
single  ovum  with  a  single  placenta,  there  is  always  a  vascular  com- 
munication in  the  placental  vessels,  usually  arterial,  less  commonly 
venous,  between  the  two  embryos. 

When  the  vascular  communication  of  the  vessels  in  the  placenta 
is  free,  and  one  foetus  is  stronger  than  the  other,  the  weaker  foetus 
is  apt  to  be  converted  into  what  is  called  an  acardiac  monster  in 

1  KoVjotta,   "Neueie    AnschauunKcn    liber    die   Entstehung  der  Doppelbilduiigen," 
Wiirzbuiger  Abharidlungeri    11)01,  Hd.  L.  Hft.  4. 

-  Ahlfeld,  Zeitschr.  f.  Gob.  u.  Gyn.,  1902,  Bd.  47,  p.  230. 


M. 


24 


370 


The  Practice  of   Midwifery. 


the  following  way.  Blood  from  the  arteries  of  the  foetus  having 
the  stronger  heart  reaches  the  arteries  of  the  weaker  foetus,  and, 
by  virtue  of  its  greater  tension,  causes  the  blood  to  flow  back  to 
the  heart,  thus  reversing  the  direction  of  the  current.-^  The  heart 
of  the  weaker  foetus,  being  no  longer  of  use,  becomes  atrophied. 
From  its  imperfect  blood  supply,  the  foetus  is  very  imperfectly 
developed,  and  generally  only  the  lower  parts  of  the  body  are 
developed  at  all,  since  the  blood,  arriving  at  the  iliac  arteries,  has 
readiest  access  to  these.  The  trunk  and  upi^er  parts  are  represented 
by  a  mere  mass  of  flesh  (see  Fig.  231).  In  rare  cases  there  is  a 
partial  development  of  the  head  and  upper  limbs.  An  acardiac 
foetus  is  thus  generally  also  acephalic.  It  must  be  distinguished 
from  the  anencephalic  foetus,  in  which  the  base  of  the  skull  is 
developed,  and  which  has  nothing  to  do  with  twin  pregnancy. 


Fig.  232. — Section  of  a  placenta  wilh   a  ftehis    conijjressus.      (Univ.    Coll. 
Hosp.  Med.  School  Mus.) 

Sex  of  the  Children — Double  monsters  are  invariably  of  the 
same  sex,  and  it  is  probable  that  the  same  law  is  generally  true  of 
all  twins  developed  from  a  single  ovum.  A  case  has  occurred  in 
the  Guy's  Hospital  Lying-in  Charity  of  twins  of  opposite  sexes 
contained  apparently  in  the  same  bag  of  membranes.  A  case  also 
has  been  recorded  of  a  healthy  female  twin  associated  with  a  male 
acephalic  foetus^  which  must  have  arisen  by  cleavage  of  the 
embryonic  area.  ^Yhen  we  remember  how  difiicult  it  often  is  to 
determine  the  exact  arrangement  of  the  membranes  in  some  of 
these  cases,  and  further  that  there  may  be  difficulty  even  in  recog- 
nising the  sex  of  a  new-born  child,  especially  if  it  be  deformed, 
the  apparent  exceptions  to  this  law  may  be  explicable  in  one  or 
other  of  these  ways.  The  statistics  of  the  Guy's  Hospital  Lying-in 
Charity  give  38  per  cent,  as  the  proportion  of  cases  in  which  both 
children  were  males,  34  per  cent,  in  which  there  was  one  of  each 
sex,  28  per  cent,  in  which  both  were  females.  According  to  German 
statistics  collected  by  Veit,  however,  it  is  most  frequent  to  find  one 
child  of  each  sex,  viz.,  in  35  to  38  per  cent,  of  the  cases. 


1  Ballantyne,  Antenatal  Pathology  :  The  Embryo,  1904,  p.  625. 

2  Dickinson,  Med.-Chir.  Trans.,  1863,  Vol.  XLVI.,  p.  141. 


Multiple   Pregnancy.  371 

Course   of  Pregnancy   in   Multiple  Gestation Twins,   and 

still  more  triplets,  are,  as  a  rule,  smaller  and  weaker  than  ordinary 
children,  and  the  mortality  among  them  is  greater  ;  they  seldom 
attain  the  same  degree  of  development  either  in  length  or  weight 
as  a  single  foetus,  but,  as  a  rule,  the  males  are  heavier  than  the 
females.  In  the  ease  of  triplets,  it  is  rare  for  all  three  to  survive, 
and  in  two-thirds  of  the  cases  labour  occurs  prematurely.  The 
uterus  and  abdomen,  however,  become   more   distended  than  in 


Fig.  233. — Adaptation  of  twins  i>i  utero  both  lying  transversely. 

ordinary  pregnancy,  and  this  condition  is  apt  to  lead  to  premature 
labour.  This  is  often  an  additional  reason  for  the  small  size  of 
twins  at  birth.  Besides  the  ordinary  risks  during  pregnancy,  a  twin 
or  triplet  has  to  incur  the  struggle  for  existence  with  the  other 
fcetus  or  fcetuses,  and  if  one  is  less  favourably  jDlaced  for  obtaining 
nutriment,  it  is  either  smaller  and  weaker,  or  may  perish  altogether. 
Thus  it  is  not  uncommon  for  one  twin  to  be  much  larger  than  the 
other  at  birth.  When  one  twin  dies  during  pregnancy  it  is 
frequently  retained  until  full  term,  and  then  expelled  with  the 
other.     Being  excluded  from  the  air,  it  does  not  become  putrid,  but 

24—2 


372 


The  Practice  of   Midwifery. 


shrinks  up,  and  becomes  mummified.  To  such  a  blighted  foetus, 
when  flattened  between  the  other  bag  of  membranes  and  the  uterine 
wall,  the  name  of  foetus  papyraceus  or  fa'tus  compressus  has  been 
given.  More  rarely,  the  dead  ovum,  perishing  at  an  early  stage, 
degenerates  into  a  mole,  either  carneous  or  vesicular.  In  other 
cases,  the  dead  foetus  acts  as  a  foreign  body,  and  sets  up  uterine 
action.  Then  either  the  dead  ovum  alone  may  be  expelled,  provided 
the  bags  of  membranes  and  placenta  are  quite  separate,  or  both 
may  be  expelled. 

Unioval  twin  pregnancy,  the  twins  having  a  common  chorion  and 

two  amniotic  cavities,  appears  to  be 
a  cause  of  hydramnios,  the  hydra- 
mnios  affecting  the  larger.  It  has 
been  suggested  that  the  heart  of  the 
stronger  twin  becomes  hypertrophied, 
through  getting  a  larger  share  of 
nutriment  from  the  placenta,  and 
causes  an  increased  secretion  of  urine. 
But  it  does  not  seem  to  be  explained 
why  this  secretion  should  be  greater 
than  in  normal  pregnancy. 

Multiple  pregnancies  undoubtedly 
expose  the  mother  to  a  greater  degree 
of  suffering  from  the  disorders  of 
j)regnancy.  Thus  there  is  likely  to  be 
greater  pressure  on  the  bladder  and 
rectum,  morning  vomiting  is  increased, 
respiration  is  more  difficult,  and  there 
is  a  greater  tendency  to  the  occur- 
rence of  albuminuria  and  of  eclampsia. 


Fig.  23d. — Adaptation  of  twins  in 
utero  with  one  vertex  and  one 
pelvic  presentation. 


Diagnosis. — A  suspicion  of  twin  pregnancy  may  be  excited  by 
unusual  size  of  the  abdomen  and  uteras,  but  no  certain  inference 
can  be  drawn  from  it.  If  the  foetuses  lie  side  by  side  they  may  be 
mapped  out  separately  by  palpation,  and  a  definite  groove  may  be 
felt  separating  them.  Special  attention  should  be  devoted  to 
discovering  whether  two  heads  can  be  felt.  The  diagnosis  is  con- 
firmed by  distinguishing  two  foetal  hearts,  of  different  rapidity, 
heard  at  two  distant  points,  the  sound  being  lost  in  the  intervening 
space.  By  listening  with  a  binaural  stethoscope,  fitted  with 
separate  tube  for  each  ear-piece,  it  may  be  possible  positively  to 
determine  that  the  two  hearts  are  asynchronous. 

In  some  cases  a  large  number  of  limbs  can  be  detected.     When 


Multiple   Pregnancy. 


375 


During  this  period  of  waiting  care  must  be  taken  to  listen  to  the 
heart  of  the  second  child  from  time  to  time,  since  after  the  birth  of  the 
first  occasionally  a  considerable  degree  of  separation  of  the  placenta 
takes  place,  and  thus  the  life  of  the  second  child  may  be  endangered. 
If  labour  is  premature  by  a  considerable  interval,  and  a  second 
child  is  enclosed  in  a  half  of  a  double  uterus  whose  orifice  is 
undilated,  it  may  be  advisable  to  leave  it,  the  first  placenta  having 
come  away,  on  the  chance  that  it  may  be  retained  some  time  longer. 
If,  however,  the  second  bag  of  membranes  presents,  this  chance*  is 


Fig.  236.— Uterus  Didelphys. 

too  remote  to  justify  postponement  of  the  puncture  of  the 
membranes. 

If  the  uterus  is  inert  in  the  second  labour  it  should  be  stimulated 
by  external  pressure,  which  may  generally  be  sufficiently  exerted 
by  a  binder.  In  some  cases,  on  this  account,  delivery  by  forceps  is 
called  for.  There  is  a  special  liability  to  post-partum  haemorrhage 
after  twin  pregnancy,  partly  on  account  of  the  excessive  size  of  the 
placental  site,  partly  because  the  uterus  is  apt  to  be  inert  after  its 
over-distension.  Special  care  must  be  taken,  therefore,  by  keeping 
up  pressure  on  the  uterus,  to  guard  against  the  risk  of  post-partum 
ha;morrhage,  and  it  is  well  to  give  a  dose  of  ergot  after  delivery  of 
the  placenta — say  one  drachm  of  the  liquid  extract.  The  physician 
should  also  watch  the  patient  longer  than  usual,  before  leaving  the 
house. 

Any  abnormal  presentation  must  be  treated  in  the  usual  way. 
The  difficultieH  which  may  arise  from  both  children  descending  into 


376 


The  Practice  of   Midwifery. 


the  pelvis  together,  and  becoming  interlocked,  will  be  considered  in 
Chapter  XXVIII. 

Superfcetation. — It  has  already  been  mentioned  that  by  super- 
fecundation  is  meant  the  fertilisation  at  a  second  coitus  of  another 


Fig.  237. — Uterus  septus,  with  septate  vagina. 


Fig.  238. — Uterus  subseptus. 

ovum  belonging  to  the  same  period  of  ovulation.  By  superfa'tation 
is  meant  the  fertilisation  of  a  second  ovum  belonging  to  another 
period  of  ovulation  after  the  iirst  ovum  has  been  developing  for  a 
month  or  more.  That  ovulation  may  occur  during  pregnancy  is 
proved  by  the  observations  of  Ldwenthal,  Slavjansky,  Martin,  and 
others. 

In  extra-uterine  pregnancy  there  is  positive  evidence  that  it  does 
occur,  for  a  five  months'  foetus  has  been  found  in  the  abdomen,  and 


Multiple   Pregnancy. 


377 


a  three  months'  foetus  in  the  uterus.  In  this  case  the  intra-uterine 
foetus  would  be  the  better  situated  for  getting  nutriment,  and  its 
inferior  development  could  not  be  due  to  failure  in  this  respect.  If 
ovulation  occurs  up  to  the  time  when,  at  about  the  fourth  month, 
the  decidua  vera  and  refiexa  come  into  contact,  and  the  decidual 
cavity  is  obliterated,  there  is  no  a  priori  impossibility  in  a  second 
ovum  becoming  implanted  upon  the  developing  mucous  membrane. 

In  the  case  of  a  double  uterus,  whether  uterus  didelphys,  uterus 
septus  or  subseptus,  or  uterus  bicornis  (see  Figs.  236 — 239),  there 
would  be  no  obstacle  to  the  production  of  super foetation  if  ovulation 
ever  occurred  during  pregnancy.  When  pregnancy  exists  in  one 
side  of  such  a  uterus,  a  decidua  is  generally  developed  on  the  other 
side  also.  Unless  this  change 
in  the  mucous  membrane 
prevented  the  implantation  of 
the  ovum,  superfoetation' need 
not  be  limited  to  the  first 
three  months  of  pregnancy, 
but  might  occur  much  later. 
In  some  cases  of  apparent 
superfoetation  the  existence 
of  a  double  uterus  has  actually 
been  verified.  It  may  have 
existed  in  others  also  without 
being  detected,  for  if  the 
septum  is  limited  to  the  body 
of  the  uterus,  and  the  os  is  single,  it  is  not  always  possible  to  dis- 
cover the  condition  during  life,  except  by  dilatation  of  the  uterus. 

Most  of  the  cases,  however,  which  have  been  adduced  as  evidence 
of  superfoetation  are  explicable  in  other  ways.  If  twins  are  born 
together  of  apparently  very  unequal  development,  this  may  be  due 
simply  to  one  twin  having  failed  to  obtain  an  equal  share  of  nutri- 
ment, as  already  described  (see  p.  370).  If  the  less  developed 
embryo  is  not  alive,  it  is  almost  certain  that  it  is  simply  a  case  of 
blighted  ovum  retained  without  decomj)osition.  The  cases  which 
are  chiefly  relied  upon  for  proving  superfoetation  are  those  in  which 
two  children,  both  of  which  survived,  have  been  born  with  an 
interval  of  some  weeks  or  months  between  them.^  Even  of  these, 
however,  most  may  be  explained  by  supposing  that  the  more 
developed  foetus  of  twins  was  born  prematurely,  and  that  the  other 
was  retained  either  in  a  single  or  double  uterus  until  it  became 


Fig.  239. — Uterus  Bicornis  Unicollis. 


1  For  a  case  of  this  kind,  in  which  the  uterus  was  double,  see  a  pajicr  by  Dr.  Ross, 
Lancet,  August,  1871. 


378 


The  Practice  of   Midwifery. 


fully  developed.  The  strongest  evidence  in  favour  of  superfcetation 
is  derived  from  one  or  two  well-established  eases  in  which  viable 
children  have  been  born  at  an  interval  of  about  four  months} 
These. can  apparently  only  be  explained  by  the  supposition  either 
that  the  first  child  was  premature  within  the  limits  of  viability,  and 
that  the  second  was  due  to  superfcetation  within  the  first  three 


Fig.  24:0. — A  twin  pregnancy.  One  foetus  has  attained  the  age  of  3 — 4 
months,  the  second  is  much  smaller.  There  are  two  placentae  and  two 
sets  of  membranes.     (Univ.  Coll.  Hosp.  Med.  School  Mus.) 


months  of  j)regnancy,  or  else  that  (the  first  child  being  born  at  full 
term)  superfcetation  had  taken  place  at  a  later  period  of  pregnancy, 
an  occurrence  which  would  be  possible  only  with  a  double  uterus. 

Many  so-called  cases  of  superfcetation  are  valueless  as  proofs  of 
the  occurrence  of  this  condition,  because  those  who  described  them 
have  failed  to  recognise  the  difficulty  of  comparing  the  develox)ment 

1  Dr.  Bonnar,  "A  Critical  Enquiry  regarding  Superfcetation,  with  Cases,"  Ediu, 
Med.  Journ.,  January,  186.5. 


Multiple   Pregnancy.  379 

of  two  children  not  born  at  the  same  time,  except  with  the  assist- 
ance of  a  very  accurate  record  of  their  appearances,  weights,  and 
measurements. 

A  case  observed  by  Dr.  Tyler  Smith  ^  affords  some  evidence  in 
favour  of  superfoetation.  A  woman  miscarried  at  the  end  of  the 
fifth  month,  and  some  hoars  afterwards  a  small  clot  was  discharged, 
enclosing  a  perfectly  fresh  and  healthy  ovum  of  about  one  month. 
The  patient  had  menstruated  regularly  during  the  time  she  had  been 
pregnant,  and  was  unwell  three  weeks  before  she  aborted.  There 
were  no  signs  of  a  double  uterus.  This  case  is  specially  interesting 
from  the  coincidence  of  menstruation  during  pregnancy  with 
supposed  superfoetation,  but  it  is  open  to  the  possible  doubt  that 
the  ovum,  though  apparently  fresh,  might  have  been  retained  after 
death  without  decomposition. 

The  conclusion  is  that  in  many  instances  superfoetation  has  been 
assumed  without  sufficient  ground,  but  that  in  very  rare  cases  there 
is  as  strong  evidence  of  its  occurrence  as  the  nature  of  the  case 
permits.  Whether  in  any  of  these  there  was  a  normal  uterus  is 
not  absolutely  certain. 

1  Manual  of  Obstetrics,  p.  172. 


Chapter  XVIL 
PHYSIOLOGY  OF  THE  PUERPERAL  STATE. 

By  the  puerperal  state  is  meant  the  condition  of  the  woman 
during  the  time  when  she  is  recovering  from  the  effects  of  labour, 
and  the  pelvic  organs  are  returning,  so  far  as  they  do  return,  to 
their  former  condition.  This  extends  over  a  period  of  as  much  as 
six  weeks  in  normal  cases,  and  is  apt  to  be  extended  longer  when 
any  disturbance  occurs.  Though  the  puerperal  state  must  be 
regarded  as,  in  the  main,  physiological,  yet  it  borders  very  closely 
on  the  pathological,  and  morbid  processes  very  readily  arise  in  it. 
The  tearing  across  of  vessels,  formation  of  thrombi  in  them,  and 
rapid  cell  production  from  the  surface  of  the  uterine  mucous 
membrane  are  different  from  anything  else  which  occurs  under 
normal  conditions.  In  a  large  proportion  of  women,  moreover, 
including  all  primiparse,  there  are  actual  traumatic  lesions  to  be 
recovered  from,  consisting  of  more  or  less  bruising  and  laceration 
of  the  vaginal  outlet  and  vulva,  not  unfrequently  also  of  the  cervix 
and  adjoining  cellular  tissue. 

The  exertion  of  labour  is  normally  followed  by  a  sense  of  extreme 
relief  and  calm.  If,  however,  labour  has  been  severe,  there  may 
be  signs  of  nervous  exhaustion.  There  may  be  a  slight  rigor,  due 
to  actual  chill  from  the  cessation  of  muscular  activity,  coupled 
with  the  cooling  of  the  skin  by  perspiration.  This  is  soon  relieved 
by  warm  clothing.  Eefreshing  sleep  generally  soon  follows,  and 
does  much  to  restore  the  patient. 

Pulse  and  Temperature. — After  natural  delivery  the  pulse 
falls  to  a  normal  rate  and  often  to  one  somewhat  below  the  normal, 
sometimes  as  low  as  50  or  even  lower.  Sometimes  the  rate  is  still 
further  diminished  on  the  second  or  third  day,  and  a  frequency  even 
as  low  as  30  ^  has  been  noted.  Frequently  the  pulse  regains  its  usual 
rate  about  the  third  to  fifth  day,  but  it  may  remain  low  as  long  as  a 
week  ;  such  retardation  of  pulse  may  be  taken  as  a  sign  that  all  is 
going  well.     Like  the  temperature,  the  pulse  of  lying-in  women  is 

1  Knapp  ;  von  "Winckel,  Handbuch  der  Geburtshiilfe,  Vol.  II.,  Part  1,  p.  145. 


Physiology  of  the   Puerperal  State.        381 

readily  affected  by  slight  causes,  whether  emotional  or  constitu- 
tional disturbances,  but  not  to  so  great  an  extent.  So  long  as  the 
disturbance  is  slight,  the  temperature  is  a  more  delicate  indication 
than  the  pulse. 

The  causation  of  this  slowing  of  the  pulse  is  somewhat  complex. 
It  has  been  attributed  to  the  fall  in  blood  pressure,  the  diminution 
in  the  vascular  area  due  to  the  cutting  out  of  the  placental  circula- 
tion, the  rest  in  bed,  reflex  stimulation  of  the  vagus  with  inhibition 
of  its  accelerator  fibres,  and  to  the  j)resence  in  the  blood  of  various 
bodies  associated  with  the  processes  of  involution. 

Temperature  is  often  raised  a  degree  or  two  during  the  latter 
part  of  labour,  if  at  all  severe  or  protracted,  and  remains  elevated 
for  a  short  time  afterwards.     Soon  it  sinks  to  the  normal  level,  and 
generally  somewhat  below   it.     Throughout  the  puerperal  state, 
and  especially  for  the  first  ten  or  fourteen  days,  the  temperature 
very  easily  becomes  elevated  from  any  slight  cause,  readily  rising- 
even  as  high  as  101°  or  102°.     Such  cause  may  be  local  inflamma- 
tion due  to  laceration  of  perineum  or  cervix,  mental  emotion  or 
shock,  irritation  of  breasts   accompanying  the  secretion  of  milk, 
or  slight  septic  absorption  at  some  exposed  surface,  which  does  not 
go  on  to  produce  more  serious  symptoms.     Even  constipation,  or 
slight  imprudence  in  diet,  appears  to  be  capable  of  causing  a  rise 
of   temperature.     All  these   causes   act   more    readily   on   highly 
neurotic   subjects.     A   rise   of   temperature   about   the  third  day 
accompanying  the  secretion  of  milk  has  even  been  considered  by 
many  authorities  to  be  a  normal  occurrence.     It  does  not  appear, 
however,  that  any  notable  rise  of  temperature  should  be  regarded 
as  necessary,  or  absolutely  normal ;  and  the  elevation  about  the 
third  day  is  probably  due,  much  more  often  than  was  formerly 
supposed,  to  a  slight  septic  or  traumatic  disturbance.     The  so-called 
"  milk-fever "  is  not  therefore  to  be  regarded  as  a  physiological 
occurrence.      In   normal   cases,    if  temperatures   are   taken  only 
twice  a  day,  it  is  exceptional  to  observe  a  rise  of  temperature  of 
more  than  about  one  degree.     Thus  of  women  after  normal  labours 
attended  in  Guy's  Hospital  Lying-in  Charity,  on  whom  observations 
on  temperature  were  made,  a  reading  above  100°  F.  at  any  time 
was   noted  in  only  12  per  cent,   even  before  the  introduction  of 
perchloride  of  mercury  as  an  antiseptic,  and  no  special  tendency 
to  elevation  about  the  third  day  was  observable.^     On  the  other 
hand,  in    lying-in   hospitals,    even   when  free  from  any  apparent 
unfavourable  influence,  a   considerable   rise   of   temperature   was 

1  Guy's  Hosp.  Reports,  Vol.  XVII. 


382  The   Practice  of   Midwifery. 

more  common  previous  to  the  recent  perfection  of  antisepsis,  by 
which  pyrexia  after  delivery  has  been,  to  a  great  extent,  banished.^ 

Hence  a  rise  of  temperature  of  more  than  two  degrees  should 
always  rouse  some  anxiety,  and  be  an  indication  for  very  careful 
watching  of  the  patient.  But  in  the  absence  of  corresponding 
elevation  of  pulse,  or  other  unfavourable  signs,  it  often  proves 
transient,  and  does  not  necessarily  mean  danger.  It  is  only  to  be 
attributed  to  the  secretion  of  milk  when  it  accompanies  some  local 
discomfort,  or  fulness  in  the  breasts,  and  subsides  as  soon  as  the 
flow  of  milk  becomes  free  and  normal. 

For  the  purposes  of  comparison  a  standard  of  so-called  morbidity 
has  been  adopted  in  many  lying-in  hospitals,  viz.,  if  the  temperature 
rises  above  100°  F.  on  two  occasions  between  the  second  and  the 
eighth  day,  the  puerperium  is  considered  to  be  abnormal,  and  the 
case  is  included  in  the  morbidity  tables. 

The  first  day  is  excluded  because  transient  rises  of  temperature 
during  the  first  twenty-four  hours  are  not  uncommon  and  of  little 
imjDortance. 

Secretions  and  Excretions. — The  skin  is  generally  moist  so 
long  as  the  patient  remains  in  bed,  and  sweating  is  readily  excited. 
The  bowels  are  sluggish.  The  secretion  of  urine  is  very  copious 
during  the  first  two  or  three  days  of  the  puerperium  ;  it  diminishes 
about  the  fourth  day  and  rises  again  at  about  the  normal  amount 
about  the  end  of  the  first  week,  after  which  it  remains  practically 
normal. 

Immediately  after  delivery,  in  nearly  50  per  cent,  of  the  cases, 
the  urine  contains  a  trace  of  albumen,  possibly  due  to  the  strain  of 
a  labour.  On  microscopic  examination  epithelium  cells,  red  blood 
corpuscles,  and  occasionally  hyaline  casts  can  be  detected,  but  both 
these  and  the  albumen  have,  as  a  rule,  disappeared  in  normal  cases 
by  the  end  of  the  first  twenty-four  hours.  Taking  into  account  the 
light  diet  and  the  rest  in  bed,  the  excretion  of  urea  is  copious,  the 
average  amount  between  the  third  and  fifth  day  being  from  26*5  to 
30  gms.,  or  approximately  the  normal  amount. 

Peptones  are  constantly  found  in  the  urine,  and  are  attributed  to 
the  processes  of  involution  occurring  in  the  muscle  fibres  of  the 
uterus.  The  amount  excreted  increases  up  to  the  fourth  day,  and 
they  disappear  about  the  twelfth  day.  The  quantity  present 
appears  to  bear  some  relation  to  the  number  of  leucocytes  in  the 


1  Dr.   E.  S.  Tait,  "  Observations  on    Puerperal  Temperatures,"   Trans.  Obst.  Soc, 
London,  1884,  Vol.  XXVI.,  p.  8. 


Physiology   of  the   Puerperal   State.        383 

blood,  and  cannot  be,  as  was  supposed  formerly,  attributed  to  the 
presence  iji  utero  of  a  dead  and  macerated  foetus. 

Acetone,  on  the  other  hand,  which  is  also  found  at  times  in  the 
urine,  is  said  to  be  specially  frequent  with  such  a  condition  of  the 
foetus.  The  amount  of  phosphates  and  sulphates  excreted  is  at  a 
maximum  on  the  first  day  of  the  puerperium ;  after  this  it  diminishes, 
and  about  the  fifth  day  rises  again  slightly.  The  excretion  of 
chlorides  is  somewhat  increased.  A  slight  degree  of  glycosuria  is 
common,  and  may  be  regarded  as  physiological.-^  It  is  noted 
especially  when  the  milk  is  first  secreted.  It  disappears  afterwards 
if  the  consumption  balances  the  secretion  of  milk,  but  appears 
again  if  the  breasts  become  over-full,  or  the  consumption  of  the 
milk  is  checked.  It  appears,  therefore,  to  be  due  to  resorption  of 
milk-sugar  from  the  secreted  milk,  or  else  to  elimination  of  sugar, 
formed  with  a  view  to  the  lacteal  secretion,  but  not  utiHsed.  The 
form  of  sugar  present  is  said  to  be  lactose,  not  glucose.  This 
would  seem  to  prove  the  origin  of  the  sugar  to  be  resorption  from 
the  breasts. 

There  is  commonly  some  difficulty  in  micturition  for  the  first  few 
days,  due  partly  to  the  mere  effect  of  position,  partly  to  the  efl:ect 
of  pressure  upon  the  neck  of  the  bladder  and  the  urethra,  and  partly 
to  slight  injuries  to  the  vulva  and  urethra  occurring  during  labour. 
Necessity  for  the  use  of  the  catheter  is,  however,  exceptional. 

Involution  of  the  Uterus. — Ehythmical  contractions  of  the 
uterus  continue  after  the  ex]3ulsion  of  the  placenta,  and  are  more 
or  less  perceptible  for  some  days  afterwards,  becoming  gradually 
less  marked  as  the  uterus  diminishes  in  size.  In  the  intervals  of 
the  active  contractions,  a  certain  amount  of  muscular  tonicity 
normally  persists.  When  the  contractions  cause  a  painful  sensa- 
tion to  the  woman,  they  are  called  "  after-pains."  The  rapid 
diminution  in  the  size  of  the  uterus  is  closely  associated  with  the 
lessened  flow  of  blood  through  it.  This  lessened  flow  depends 
mainly  upon  two  causes  :  first,  the  removal  of  the  stimulus  caused 
by  the  presence  of  the  growing  ovum  ;  secondly,  the  compression 
of  the  vessels  produced  by  the  retraction  and  closure  of  the  emptied 
uterus  and  the  maintenance  of  a  tonic  contraction  of  its  walls. 
The  process  of  reduction  in  size  goes  on  most  actively  for  the  first 
week  after  delivery.  After  this  it  continues  with  diminishing 
rapidity,  and  is  not  complete  until  from  six  to  eight  weeks  have 
passed, 

'  IJe  Slrif^ty,  "  Recherches  sur  I'Uiinc  pendant  la  Lactation,"  Gaz.  M6el.  de  Paris, 
187;i 


384 


The   Practice  of   Midwifery. 


Immediately  after  delivery  the  uterus  occupies  the  greater  part 
of  the  pelvic  cavity,  and  is  somewhat  anteverted  and  flattened  from 


1    pS'Oi*''-', 


.h: 


Fig.  241. — Section  of  the  uterus  from  a  patient  dying  five  minutes  after 
delivery.  The  thickness  of  the  retracted  uterine  walls,  the  collapsed 
lower  uterine  segment,  and  the  flattening  of  the  cervix  against  the^ 
posterior  vaginal  wall  are  well  shown.  (Webster,  Pelvic  Anatomy, 
Plate  II.) 


before  backward.  On  section  a  distinction  can  be  made  out  clearly 
between  the  upper  uterine  segment,  the  lower  segment,  and  the 
cervix.      The   well-marked   ring   which  can  be   felt  through   the 


Physiology  of  the   Puerperal  State.        385 

cervical  canal  is,  as  Webster  ^  has  pointed  out,  the  lower  edge  of  the 
retraction  ring,  and  not  the  internal  os.  The  uterus  is,  as  a  whole, 
symmetrically  placed  in  the  pelvis,  and  is  not  rotated. 


ot  'i^j,-^^-'^,-,. 


Fig.  242. — Section  of  uterus  on  the  third  day  of  the  puerperium.  The  slight 
diminution  in  size  of  the  uterus  is  to  be  noted.  The  flaccid  condition 
of  the  lower  uterine  segment  has  disappeared.  |(Webster,  Pelvic 
Anatomy,  Plate  VII.) 


Owing  to  the  loosening  of  the  attachments  of  the  uterus  to  the 
vagina  and  other  structures,  it  is  capable  of  a  considerable  degree 
of  movement,  and  this  is  well  shown  in  the  marked  displacement 

1  Webster,  Researches  in  Female  Pelvic  Anatomy,  1892. 

M.  25 


386 


The   Practice  of   Midwifery. 


which  may  occur  as  the  result  of  over-distension  of  the  bladder. 
After  the  first  day  the  distinction  between  the  three  portions  of  the 
uterus  disappears. 

The  dimensions  of  the  uterus  immediately  after  delivery  are  as 


Fig.  243. —  Section  of  uterus  uii  sixth  day  of  puerperiiim.  The  uterus  is  now 
below  the  level  of  the  pelvic  brim.  (Webster,  Pelvic  Anatomy, 
Plate  XII.) 


follows  :  length,  15  cm.  (6  inches) ;  breadth,  11 — 12  cm.  (4f  inches) ; 
depth,  7 — 8*5  cm.  (3f  inches);  thickness  of  the  walls,  3h — 5  cm. 
(If — '2  inches).  At  this  period  the  sound  passes  into  the  uterine 
cavity  about  11*5  cm.  (4|  inches),  on  the  tenth  day  about  10*5  cm. 
(4^  inches),  at  the  end  of  the  fifteenth  day  9"8  cm.  (3f  inches),  at 


Physiology   of   the   Puerperal   State.        387 

the  end  of  the  fourth  week  8  cm.  (S^  inches),  and  at  the  end  of  the 
sixth  week  7  cm.  (2f  inches).  Webster  has  shown  that,  owing  to 
the  extreme  folding  of  the  lower  uterine  segment  and  cervix  which 
is  usually  present,  attempts  to  measure  the  length  of  the  uterine 
cavity  with  the  sound  are  likely  to  lead  to  inaccurate  results.  From 
a  study  of  frozen  sections  he  finds  the  cavity  of  the  uterus  to 
measure  6^  inches  (15'5  cm.)  at  the  beginning  of  the  puerperium, 
and  4f  inches  (11"5  cm.)  on  the  sixth  day.  The  uterus  weighs 
about  1  kilo,  immediately  after  delivery  (35  ounces),  at  the 
end  of  the  first  week  ^  kilo.  (17  ounces),  at  the  end  of  the 
fortnight  J  kilo.  (11  ounces),  and  at  the  end  of  the  third  week 
^  kilo.  (9  ounces).  By  the  end  of  the  seventh  week  it  has 
regained  its  normal  weight  of  50 — 60  grms.  (2  ounces).  Immedi- 
ately after  delivery  the  height  of  the  fundus  above  the  pubes  is 
on  an  average  between  5  and  6  inches  (12 — 15  cm.),  but  varies 
much  in  different  cases.  It  may  be  as  much  as  7  or  8  inches 
(17"5 — 20  cm.).  A  few  hours  after  delivery,  even  up  to  twelve  hours, 
the  fundus  generally  appears  to  be  higher  than  before.  This  is 
attributed  to  the  filling  of  the  bladder  and  rectum,  which  elevate 
the  uterus  out  of  the  pelvis.  A  diminished  intensity  of  the  tonic 
contraction  of  the  uterine  wall  and  a  recovery  of  the  tone  of  the 
vaginal  walls  may  also  contribute  to  the  effect. 

Frozen  sections  appear  to  show  that  there  is  very  little  change 
in  the  uterus  during  the  first  four  days  of  the  puerperium,  after 
which  as  involution  proceeds  a  gradual  diminution  in  size  occurs, 
and  at  the  end  of  a  week  the  fundus  is  about  three  inches  (7'5  cm.) 
above  the  pubes,  the  descent  of  the  fundus  taking  place  at  about  the 
rate  of  1  cm.  a  day.  At  the  end  of  two  weeks  the  fundus  is 
still  as  much  as  1^  inches  above  the  pubes,  but  soon  after  this 
it  becomes  difficult  to  feel  it  by  external  examination  alone. 

The  mechanism  of  the  process  of  involution  is  that  the  enormously 
hypertrophied  muscle  fibres  of  the  pregnant  uterus  undergo  a 
gradual  diminution  in  size.  Some  of  the  older  observers  described 
a  complete  destruction  of  the  muscle  fibres  with  fatty  degeneration, 
but  this  has  not  been  confirmed  by  more  recent  observa- 
tions. Sanger  has  made  a  careful  study  of  the  changes  occurring 
in  the  fibres,  and  describes  a  gradual  diminution  in  their  breadth 
and  length  to  such  a  degree  that  at  the  end  of  involution  the  fibre 
is  actually  shorter  than  it  is  in  the  normal  non-pregnant  uterus. 
The  fibres  have  under  the  microscope  a  slightly  granular  and 
hyaline  appearance,  which  is  probably  due  rather  to  a  process  of 
albuminoid  degeneration  than  to  fatty  degeneration.  The  proto- 
plasm of  the  fibres,  no  doubt,  is  in  large  part  oxidised  without  the 

25—2 


388 


The  Practice  of   Midwifery. 


occurrence  of  any  fatty  change.     Helme,  from  a  study  of  the  process 
in  the  uterus  of  the  rabbit,  regards  the  change  as  a  process  of 


Fig.  2i4. — Section  of  the  uterus  upon  the  twenty-sixth  day  of  the  puerperium. 
The  uterus  is  now  entirely  an  intrapelvic  organ.  (Varnier,  Pratique  des 
Accouchements,  Fig.  323.) 


peptonisation  of  the  protoplasm  with  absorption  of  the  soluble 
material  by  the  circulation  and  resulting  diminution  in  size  of  the 
fibres.  Hyaline  and  granular  degeneration  also  affects  the  con- 
nective tissue.     He  found  no  evidence  of  the  formation  of  any  new 


Physiology  of  the   Puerperal   State.        389 

fibres.  As  we  have  seen,  peptonuria  is  fairly  constant  in  the  puer- 
perium.  Other  observers  have  described  a  discharge  of  glycogen  from 
the  uterus  and  a  rapid  absorption  of  water  during  the  first  twenty- 
four  hours  after  delivery.  It  is  probable  that  the  process  of 
autolysis,  due  to  the  action  of  intracellular  ferments,  plays  an 
important  part  in  the  changes  in  the  protoplasm  of  the  muscle  cells 
associated  with  involution.  The  proper  performance  of  involution 
depends  upon  a  due  action  of  the  absorbent  system,  as  well  as  upon 
the  diminution  of  the  blood  supply.  It  is  apt  to  be  interfered  with 
by  any  constitutional  condition  which  impairs  this,  as  well  as  by 
any  cause  which  prevents  the  proper  contraction  of  the  circulation. 
According  to  Sanger,^  three  conditions  are  necessary  :  increased 
oxidation,  ansemia  of  the  muscle  fibres,  and  continuous  retraction 
and  contraction. 

The  arteries  which  have  been  so  greatly  increased  in  size  during 
pregnancy  become  diminished  by  the  contraction  of  their  calibre. 
Their  walls,  however,  remain  thicker  than  in  the  unimpregnated 
uterus,  a  diminution  in  the  lumen  from  obliterative  endarteritis 
occurs,  and  this  change  is  a  permanent  one.  Thus,  in  a  section  of 
the  parous  uterus  after  involution,  the  arteries,  which  are  apparently 
more  numerous  than  in  the  nulliparous  organ,  project  beyond 
the  surrounding  surface,  present  thick  yellowish  white  walls,  more 
opaque  than  the  tissues  around,  and  their  canals  remain  patent. 

The  obliteration  of  the  large  venous  sinuses  of  the  placental  site 
takes  place  in  the  following  manner :  After  delivery,  thrombi  are 
formed  in  them.^  Then  j)roliferation  of  the  lining  membrane 
takes  place ;  it  undergoes  hyaline  degeneration,  and  forms  a  glassy- 
looking  transparent  substance,  thrown  into  folds,  reminding  one  of 
the  appearance  presented  by  a  corpus  luteum.  This  folded  layer, 
in  some  cases,  completely  closes  the  channel.  In  others  the  centre 
is  occupied  by  the  remains  of  the  thrombus,  which  has  become 
organised,  apparently  by  the  growth  into  connective  tissue  cells 
either  of  the  leucocytes  contained  in  it,  or  of  wandering  nuclei 
from  the  tissues.  These  changes  are  most  fully  developed  at  the 
end  of  four  weeks.  But  even  up  to  the  end  of  twelve  months  the 
convoluted  appearance  may  still  be  discernible.  It  may  therefore 
be  of  great  importance  as  medico-legal  evidence  of  a  previous 
pregnancy.'^ 

1  Siinger,  lieitriiKe  zui;  I'iith.  Anat.  u.  Klin.  Med.  von  Wagner's  Schulern,  1S87, 
p.  134. 

-  According  to  some  authorities,  thrombosis  of  the  sinuses  begins  a  month  or  so 
before  delivery,  IjiiL  it  is  probaVjlc  tliat  this  is  a  morbid,  not  a  normal,  process. 

"  "  Changes  in  the  Uterus  resulting  from  Gestation,"  by  Sir  J.  Williams,  Trans, 
Obst.  Soc.  London,  1878,  Vol.  XX.,  p.  172. 


390  The  Practice  of   Midwifery. 

Changes  in  the  Mucous  Membrane. — The  portion  of  the 
decidua  vera  superficial  to  the  ampullary  layer  (see  Fig.  53,  p.  77) 
normally  comes  away  as  a  layer  blended  with  the  chorion.  The 
remainder,  covered  with  a  layer  of  blood  and  fibrin,  remains  attached 
for  a  time  to  the  interior  of  the  uterus.  Gradually  the  superficial 
part  of  it,  consisting  mainly  of  the  ampullary  layer  itself,  with  some- 
times portions  of  the  upper  cellular  layer  still  remaining  attached, 
breaks  up,  becomes  necrotic,  undergoes  fatty  degeneration,  and  is 
discharged  in  shreds  with  the  lochia.  The  muscular  wall  of  the 
uterus  is  never  entirely  laid  bare,  for  the  deepest  layer  of  mucous 
membrane  remains  attached,  including  the  dilated  extremities  of 
the  glands.  The  interglandular  part  of  the  mucous  membrane  is 
reconstituted  by  proliferation  of  the  connective  tissue  cells.  The 
cylindrical  epithelium  lining  the  new  glands,  and  that  which 
eventually  covers  the  mucous  surface,  is  probably  derived  from 
the  epithelium  which  remained  at  the  deepest  portion  of  the  old 
glands,  and  which  undergoes  marked  proliferation,  mitotic  figures 
being  very  numerous.  The  new  epithelium  is  fully  formed  by  the 
middle  of  the  fourth  week  of  the  puerperium. 

The  Placental  Site. — The  portion  of  mucous  membrane  left 
over  the  placental  site  is  thinner  than  elsewhere,  so  that  the 
muscular  wall  is  more  nearly  exposed.  The  regeneration  of 
mucous  membrane  takes  place  more  slowly  over  this  surface, 
and  the  involution  of  the  uterine  substance  is  also  slower  at  the 
placental  site.  Hence,  about  a  week  or  ten  days  after  delivery, 
the  placental  site  forms  a  prominence  with  uneven  surface,  convex 
toward  the  uterine  cavity.  This,  in  some  cases,  it  might  be 
possible  at  first  sight  to  mistake  for  a  new  growth  in  the  uterine 
wall,  or  portion  of  adherent  placenta.  It  remains  readily  recog- 
nisable until  the  sixth  week  after  delivery,  and  finally  disappears 
during  the  course  of  the  third  month. 

The  Cervix  Uteri  and  Vagina. — The  internal  os  takes  part 
in  the  contraction  of  the  uterine  body  on  the  expulsion  of  the 
placenta.  Contraction  is  indeed  specially  marked  at  this  part,  so 
that  the  internal  os  can  be  felt  from  the  inside  as  a  definite 
ring.  It  remains,  however,  for  a  time  large  enough  to  admit  one 
or  two  fingers.  The  cervix  does  not  take  part  in  the  contrac- 
tion, and  continues  for  a  considerable  time  thin,  soft,  and  flaccid, 
having  a  length  of  about  three  inches  or  more.  Its  edges  are 
frequently  irregular  from  laceration,  and  sometimes  the  lacera- 
tion extends  as  deeply  as  the  vaginal  reflexion.  When  the 
laceration  is  deep,  it  is  most  frequently  either  on  the  left  side, 


Physiology  of  the   Puerperal   State.        391 

or  bilateral,  the  cleft  on  the  left  side  being  the  deeper.  The 
reason  of  this  appears  to  be  that  the  occiput  is  most  commonly 
directed  toward  the  left  side,  and,  escaping  first  from  the  ring 
of  the  cervix,  is  most  likely  to  cause  laceration  of  it.  The  internal 
OS  may  remain  patent  enough  to  admit  the  finger  for  a  week  or 
more,  but  usually  ceases  to  be  so  after  ten  days,  and  is  quite 
reformed  by  the  third  week.  The  cervical  canal  remains  patulous 
for  a  longer  time,  and  its  involution  is  not  complete  till  the 
end  of  six  or  seven  weeks.  Involution  of  the  vagina  occupies  about 
the  same  time  as  that  of  the  uterus.  After  a  first  delivery  its 
outlet  remains  permanently  wider  than  before,  as  the  clefts  which 
have  been  torn  in  it  do  not  entirely  unite  again,  but  heal  up  by 
granulation.     The  vaginal  rugae  reappear  about  the  third  week. 

The  Lochia — A  discharge  takes  place  for  the  first  two  or  three 
weeks  after  delivery,  called  the  lochia,  or  lochial  discharge.  It 
arises  from  the  internal  surface  of  the  body  of  the  uterus,  with  the 
addition  of  the  secretion  of  the  cervix  and  vagina.  At  first  the 
discharge  is  almost  pure  blood.  With  it  may  be  passed  large 
clots,  especially  if  the  uterus  is  not  well  contracted,  so  that  blood 
is  poured  out  more  freely,  and  space  and  time  allowed  for  it  to 
coagulate  within  the  uterus.  For  the  first  three  days  blood  still 
predominates,  but  is  mixed  with  serous  exudation,  leucocytes, 
epithelial  cells,  shreds  of  decidua,  and  fatty  and  granular  cells 
derived  from  the  degenerating  decidua.  Clots,  generally  small, 
may  still  be  passed  from  time  to  time.  After  the  third  or  fourth 
day,  the  proportion  of  blood  diminishes,  and  that  of  serous  fluid 
increases.  The  colour  of  the  discharge,  hitherto  dark  red  (lochia 
rubra  or  cruenta),  now  becomes  paler  {lochia  serosa).  The  propor- 
tion of  blood  corpuscles  progressively  diminishes,  and  that  of  the 
other  constituents,  especially  the  leucocytes,  increases.  About  the 
ninth  day  the  colour  becomes  yellowish  grey,  or  slightly  greenish, 
from  a  small  quantity  of  blood  being  still  present  {lochia  alba, 
green  -waters).  The  constituents  at  this  time  are  chiefly  leucocytes, 
granular  cells,  fat,  epithelial  cells,  and  cholesterine  crystals.  From 
this  time  the  discharge  gradually  diminishes  until  it  merges  into 
the  character  of  the  non-puerperal  secretion. 

The  reaction  of  the  lochia  is  alkaline  or  neutral  at  first,  while 
the  discharge  is  abundant.  After  a  few  days,  as  the  quantity 
diminishes,  it  becomes  acid  in  the  vagina,  the  usual  reaction  of  the 
vaginal  secretion  preponderating.  The  discharge  has  a  peculiar, 
disagreeable  smell,  from  the  secretion  of  the  glands.  It  very 
readily  ]>ecomes  decomposed  upon  the  napkins,   but,   within  the 


392  The   Practice  of   Midwifery. 

vagina,  it  has  not  normally  the  odour  of  decomposition.  If  such 
an  odour  is  observed,  it  indicates  the  probability  of  some  clots  or 
placenta  being  retained,  unless  due  to  septic  infection  conveyed 
from  without.  It  has  been  found  that,  after  the  first  day  or  two, 
the  lochial  fluid  has  a  toxic  influence,  if  injected  into  the  tissues 
of  animals,  and  that  this  becomes  during  the  first  week  greater 
the  greater  the  interval  after  delivery.^  It  is  probable  that 
normally,  before  this  deleterious  quality  is  developed,  any  breaches 
of  surface  in  the  genital  canal  become  covered  with  granulations, 
and  so  protected  from  absorbing  readily.  Normally  micro- 
organisms are  not  present  in  the  uterus.  In  the  discharge  from 
the  vagina,  saprophytes  abound,  but  the  most  modern  observa- 
tions appear  to  show  that  pyogenic  organisms  are  normally  not 
present.-  Cocci,  however,  are  present  in  greater  proportion  than 
in  pregnancy,  during  which  condition  bacilli  preponderate. 

The  quantity  of  the  lochial  discharge  varies  much  in  different 
women,  like  that  of  the  menstrual  flow,  and  is  apt  to  be  more 
abundant  with  those  who  habitually  menstruate  profusely.  It  is 
also  influenced  by  the  age  of  the  patient,  being  more  abundant  in 
young  women,  the  management  of  the  third  stage  of  labour,  and 
the  taking  of  alcohol.  Generally  the  quantity  is  greater  if  the 
woman  does  not  suckle,  the  stimulus  to  uterine  contraction  being 
lost.  After  the  red  colour  has  ceased,  it  is  apt  to  return  about  the 
fourteenth  to  twentieth  day,  especially  if  the  woman  gets  about 
too  soon  or  exerts  herself  too  much,  no  doubt  as  a  result  of  the 
dislodgment  of  small  thrombi. 

The  total  amount  of  the  lochial  discharge  is  from  500  to  1,000 
gms.  (17 — 35  ounces).^  Giles^  estimates  the  amount,  however,  as 
less  than  20  ounces. 

In  women  who  do  not  suckle  the  periods  return  as  a  rule  six  to 
eight  weeks  after  their  confinement,  and  in  those  who  do  suckle 
on  the  cessation  of  lactation. 

Condition  of  the  Blood. — During  the  puerperal  state  the  blood 
exhibits  a  diminution  in  the  number  of  red  corpuscles  and  in  the 
amount  of  haemoglobin  during  the  first  two  days,  a  result  probably 
due  to  the  hsemorrhage  at  delivery  and  the  lochial  discharge.  At 
the  end  of  ten  days  the  deviations  from  the  normal  as  to  leucocy- 
tosis,  diminution  of  red  corpuscles,  and  diminution  of  hgemoglobin 

1  Kehrer,  Arch.  fur.  Gynak.,  1877,  Bd.  1],  H.  2,  p.  348. 

2  Kronig,  Bacteriologie    des    Genitalkanales  der   Schwangeren,   Kreissenden,   imd 
Puerperalen  Frau,  Leipzig,  1897. 

3  Bumm,  Grundriss  zur  Studium  der  Geburtshilfe. 

■*  Giles,  Trans.  Obst.  Soc.  London,  1893,  Vol.  XXXV.,  p.  190  ;  Fehling,  Wochenbett., 
p.  18. 


Physiology  of  the  Puerperal   State.        393 

are  reduced,  on  the  average,  to  less  than  a  third  of  their  amount  at 
the  time  of  delivery.  The  reduction  of  the  leucocytosis  is  most 
rapid  during  the  first  three  or  four  days.  Thus,  on  the  fifth  day, 
the  average  count  of  leucocytes  per  cubic  millimetre  is  about 
12,000  as  compared  with  about  21,000  at  delivery.  The  normal 
count,  for  healthy  young  women,  is  variously  estimated  at  from 
7,500  to  9,000.^  In  using  the  method  of  examination  of  the  blood 
as  an  aid  to  the  diagnosis  of  septicaemia,  it  is  important  to  bear  in 
mind  both  the  normal  leucocytosis  and  its  normal  rapid  diminution. 

Body  Weight. — A  definite  loss  in  body  weight  occurs  during 
the  puerperium.  According  to  von  Winckel,  this  amounts  to  about 
6'8  per  cent,  of  the  total  body  weight,  and  is  mainly  due  to  the 
lochial  discharge  and  to  the  milk.  It  is  greater  in  multiparas  and 
in  suckling  women. 

After-pains. — The  intermittent  contractions  of  the  uterus, 
which  continue  after  delivery,  serve  to  expel  any  clots  which  may 
be  retained  within  the  uterus,  and  assist  in  diminishing  its  blood 
supply.  They  occur  normally  in  all  cases,  but  are  only  termed 
after-pains  when  they  cause  a  i^ainful  sensation,  either  in  conse- 
quence of  the  vigour  of  the  contractions  or  of  undue  sensitiveness 
of  the  uterus.  Such  after-pains  are  most  marked  for  the  first  day 
after  delivery,  but  they  may  jpersist,  with  diminishing  severity,  for 
four  or  five  days.  They  are  generally  excited  by  the  presence  of 
some  clots  or  shreds  within  the  uterus,  but  their  intensity  varies 
also  with  the  nervous  sensibility  of  the  patient,  so  that,  in  this 
respect,  they  are  in  some  measure  analogous  to  the  pain  of 
dysmenorrhcea.  They  are  scarcely  noticed  when  a  good  continuous 
uterine  contraction  is  secured  from  the  first,  and  no  clots  are 
formed  within  the  uterus.  Thus  in  primiparge  they  are  absent, 
as  a  rule,  and  are  most  marked  in  women  who  have  had  many 
children,  or  when  the  uterus  has  been  over-distended,  as  by  twin 
pregnancy.  They  are  more  marked  when  pains  have  been  feeble 
during  delivery  than  when  they  have  been  violent.  After-pains 
are  excited  in  a  reflex  manner,  as  uterine  contraction  always  is, 
by  suckling  the  infant. 

After-i^ains  are  thus  salutary,  in  a  measure,  in  that  they  cause 
the  expulsion  of  clots.  But  it  is  still  better  to  avoid  them  by 
preventing  the  formation  of  clots.  The  best  prophylactic  is  to 
make  sure  that  the  uterus  is  emptied  of  clots  at  the  completion  of 

1  Sec  Henderson,  "  Obsoivations  on  the  Maternal  lilood  at  Term  and  during  the 
I'lierperiuin,"  .iourn,  of  Obstet.  and  Oyn.  lirit.  Eiiif).,  February,  1!)02,  Vol.  I.,  p.  ICS. 


394  The  Practice  of   Midwifery. 

the  third  stage  of  labour,  and  that  a  good  contraction  is  maintained 
afterwards, 

Affcer-pains  are  distinguished  by  their  intermittent  character, 
and  by  the  absence  of  tenderness  or  constitutional  disturbance. 
The  fundus  uteri  may  also  be  felt  to  harden  with  the  pain. 

Secretion  of  Milk. — The  evolution  of  the  breasts  during 
pregnancy  has  been  already  described  (see  p.  164).  The  typical 
appearance  of  a  section  of  the  mammary  gland,  as  generally  shown 
in  figures,  in  which  each  acinus  is  regularly  lined  with  a  mosaic  of 
polyhedral  granular  cells,  exists  only  when  the  function  of  lactation 
is  in  full  exercise.  Before  evolution,  and  during  its  earlier  stages, 
the  acinus  is  filled  irregularly  with  cells,  whose  character  varies 
according  to  the  stage  of  evolution.  By  the  time  of  delivery  the 
cells  have  become  large,  round,  containing  a  nucleus  and  fat 
particles,  often  vacuolated,  and  regularly  arranged  round  the  wall 
of  the  acinus,^  which  contains  also  some  mucoid  fluid. 

The  small  quantity  of  secretion  for  the  first  two  days  after 
delivery  is  called  colostrum,  and  does  not  differ  materially  from  the 
fluid  which  may  be  squeezed  from  the  breasts  before  delivery.  It 
is  a  clear,  somewhat  slimy,  mucoid  fluid,  containing  yellowish 
ojDaque  dots  and  streaks.  These  dots  and  streaks  are  made  up  of 
the  colostrum  corpuscles,  large  nucleated  cells,  granular  with  fat 
particles.  The  colostrum  corpuscles  are  polynuclear  leucocytes, 
which  find  their  way  into  the  acini  of  the  breast,  take  up  fat 
corpuscles,  and  pass  out  into  the  lymphatics  and  capillaries. 

Milk  corpuscles  also  are  already  j)resent.  Besides  having  the 
colostrum  corjDuscles,  colostrum  differs  from  milk  in  containing 
much  less  casein,  but  more  globulin  and  lactalbumen  ;  a  precipitate 
is  therefore  formed  on  boiling  it.  Colostrum  has  a  laxative  effect 
on  the  infant.  If  therefore  the  child  is  put  early  to  the  breast, 
there  is  no  need  to  give  it  the  castor  oil  which  many  nurses  are 
fond  of  administering. 

About  the  third  day  the  breasts  become  full,  congested,  sensitive, 
and  often  somewhat  knotty.  The  thin  bluish  milk  now  appears 
in  abundance,  and  takes  the  place  of  the  colostrum.  For  a  while 
some  colostrum  corpuscles  may  still  be  seen  on  microscopic 
examination,  but  the  milk  corpuscles,  minute  round  fat  globules, 
now  become  the  predominant  constituent.  These  are  formed 
within  the  secreting  cells,  from  which  they  find  their  way  into  the 
interior  of  the  acini. 

It  has  already  been  explained  that  the  so-called  "  milk-fever," 

1  Physiology  and  Pathology^  of  the  Breast,  by  Dr.  C.  Creighton. 


Physiology  of  the    Puerperal    State.        395 

to  which  the  synonyms  of  "  ephemera "  or  "  weid "  have  been 
given,  is  not  to  be  regarded  as  a  physiological  occurrence,  and  that 
a  rise  of  temperature  about  the  third  day  is  often  due  to  some 
transient  septic  or  traumatic  disturbance.  Febrile  disturbance 
may,  however,  be  produced  about  this  time  by  irritation  and 
tension,  or  a  slight  degree  of  inflammation,  in  the  breasts,  especially 
if  suckling  is  difficult  at  first  on  account  of  an  undeveloped  or 
flattened  condition  of  the  nipples.  "When  it  occurs  it  is  to  be 
regarded  as  the  constitutional  disturbance  set  up  by  a  local 
cause. 

Composition  of  the  Milk. — The  casein  is  formed  by  the 
gland  epithelium  from  the  albumen  of  the  blood.  The  milk-sugar 
or  lactose,  as  well  as  the  fat  in  the  form  of  milk  globules,  is  also 
formed  in  the  gland.  The  minute  oil  globules  are  believed  to  be 
kept  in  emulsion  by  the  dissolved  casein  forming  a  film  around 
them.  The  average  proportion  of  the  solid  ingredients  in  human 
milk  is  as  follows : — Fat,  2"4  per  cent. ;  casein,  1'9  per  cent. ; 
milk-sugar,  6"3  per  cent.  ;  salts,  0'34  per  cent. ;  a  trace  of  the 
lactalbumen,  present  in  the  colostrum,  still  remains,  about  0*4  per 
cent.  Hence  a  precipitate  of  slight  flocculi  is  formed  on  boiling 
milk.  The  proportion  of  butter  may,  however,  vary  between  2*4 
and  7  per  cent. ;  of  casein,  between  1"9  and  4  per  cent. ;  of  milk-sugar, 
between  3'5  and  6  per  cent.  The  proportion  of  fat  increases  up  to 
the  end  of  the  first  month  and  then  diminishes,  while  the  proportion 
of  sugar  increases  for  the  first  three  months. 

The  quantity  of  milk,  in  women  who  are  able  to  nurse  well, 
increases  uj)  to  about  six  or  seven  months,  after  which  it  diminishes. 
This  is  an  indication  that  it  is  desirable,  at  this  time,  to  begin  to 
give  the  infant  other  food  in  addition.  As  time  goes  on  the 
relative  proportion  of  casein  becomes  greater,  that  of  butter  and 
milk-sugar  less.  In  feeble  women  the  milk  often  diminishes  or 
disappears  after  three  or  four  weeks,  either  because  the  supj)ly  to 
the  system  derived  from  the  involution  of  the  uterus  then  fails,  or 
because  the  woman  is  not  strong  enough  to  produce  milk  in  addition 
to  the  expenditure  of  energy  in  being  up  and  about. 

Diagnosis  of  the  Puerperal  State.  —  The  woman  has  the 
general  appearance  of  having  passed  through  some  illness,  especially 
if  delivery  Ijas  been  concealed.  The  abdomen  is  often  slightly  full, 
but  lax,  and  the  skin  wrinkled.  Skin  cracks  (linese  gravidarum), 
red  or  white,  are  generally  present.  Pigmentation  is  usually 
visilde  in  various  parts,  and  especially  in  the  form  of  a  central  dark 


396  The   Practice  of   Midwifery, 

line  from  ensiform  cartilage  to  pubes.  This  becomes  much  more 
marked  during  the  first  few  days  after  delivery  than  it  is  during 
jjregnancy.  The  breasts  are  full,  generally  contain  colostrum  or 
milk,  and  show  the  other  changes  associated  with  pregnancy  and 
lactation.  The  fundus  uteri  can  usually  be  felt  above  the  pubes 
up  to  about  the  fourteenth  day.  For  a  much  longer  time  its  large 
size  can  be  detected  on  bimanual  examination.  The  vagina  is  lax 
and  gaping,  and  often  shows  lacerations,  especially  at  the  border  of 
the  perineum ;  the  hymen,  if  any  of  it  remains,  is  torn  completely 
to  its  base.  The  cervix  is  soft  and  patulous ;  its  edges  often  show 
lacerations  or  bruising.  The  internal  os  is  smaller,  but  may  be 
large  enough  to  admit  the  finger  into  the  uterus.  The  lochial 
discharge  will  generally  be  present,  its  character  depending  upon 
the  interval  since  delivery.  The  characteristic  softness  of  the 
tissues  in  the  puerperal  state,  especially  of  the  cervix,  vagina,  and 
perineum,  is  absent  in  pathological  conditions,  or  after  operations 
within  the  pelvis. 

Diagnosis  by  these  signs  will  rarely  be  difficult  within  ten  or  four- 
teen days  after  delivery.  In  case  of  doubt,  toward  the  end,  or  after 
the  end,  of  that  period,  observation  of  the  progressive  diminution 
in  size  of  the  uterus  may  be  of  value.  An  apjDroximate  estimate 
may  be  formed  of  the  date  of  delivery  by  the  height  of  the  fundus 
uteri  above  the  pubes,  by  the  character  of  the  lochia,  of  the  secretion 
in  the  breasts,  whether  colostrum  or  milk,  by  the  condition  of  any 
lacerations,  whether  granulating  or  cicatrised,  and  by  the  degree  of 
relaxation  of  cervix  and  vagina. 

Diagnosis  of  Parity. — To  diagnose,  after  a  considerable 
interval,  whether  a  living  woman  has  borne  children,  is  often 
difficult.  The  most  reliable  signs  are  to  be  found  in  the  conditions 
of  the  vaginal  outlet  and  hymen.  From  the  eftect  of  coitus,  the 
hymen  only  becomes  notched  at  its  edges,  while  the  whole  circuit 
of  its  vaginal  attachment  may  still  be  traced  as  intact.  After 
parturition,  in  some  cases,  it  is  broken  up  into  sections,  separated 
from  each  other  by  smooth  patches  of  mucous  membrane,  the 
result  of  lacerations  reaching  completely  down  to  the  vaginal  wall. 
In  others,  the  hymen  is  only  represented  by  projecting  tags  of 
mucous  membrane  here  and  there,  the  so-called  carunculse  myrti- 
formes  ;  while  in  others  again,  in  which  the  broken-up  fragments 
have  sloughed  away  after  labour,  no  trace  of  it  remains.  This 
characteristic  condition  of  the  hymen  in  the  parous  woman  is 
produced,  not  merely  by  its  more  extensive  laceration,  but  by  the 
sloughing  of  some  intermediate  portions  from  the  eftect  of  bruising 


Physiology  of  the   Puerperal  State.        397 

and  pressure.  The  only  thing  which  could  possibly  simulate  the 
effect  of  parity  in  a  nulliparous  woman  is  the  delivery  of  a  large 
tumour,  such  as  a  fibroid,  through  the  vagina.  Deficiency  of  the 
perineum,  indicating  a  former  rupture,  is  a  valuable  sign  when  it 
exists. 

The  presence  of  white  lines  on  the  abdomen  (lineae  gravidarum), 
indicating  old  skin  cracks,  justifies  only  a  suspicion  of  a  previous 
pregnancy,  for  these  may  result  from  distension  by  a  tumour,  or 
even  merely  by  fat. 

Changes  in  the  Cervix. — Changes  in  the  cervix  are  significant  when 
observed,  but  their  absence  proves  little  or  nothing,  since,  when  no 


'\ 


Fig.  245. — External  views  of  the  nullipai'ous  and  parous  uterus. 

laceration  occurs,  the  cervix  may  return  almost  completely  to  its 
former  condition.  As  a  rule,  in  the  nulliparous  uterus,  the  os  is 
oval,  smooth,  and  comparatively  small.  In  the  parous  uterus  it  is 
a  wider  lateral  cleft,  dividing  the  cervix  more  or  less  into  an 
anterior  and  posterior  lip.  If  there  is  a  deep  lateral  cleft  on  one  or 
both  sides,  especially  if  the  anterior  and  posterior  lips  are  rolled 
apart,  and  so  altered  by  hyperplasia  that  they  offer  some  resistance 
when  an  attempt  is  made  to  draw  them  together,  the  evidence  is 
still  stronger.  These  conditions  of  the  cervix  may  be  recognised 
by  digital  touch  alone,  and  the  conclusion  may  also  be  confirmed 
by  examination  through  the  speculum.  A  Sim's  speculum  should 
be  used,  and  given  to  an  assistant  to  hold.  To  demonstrate  any 
eversion  of  the  cervix,  the  physician  should  take  a  Sim's  sharp 
tenaculum  hook  in  each  hand,  fix  one  in  each  lip  of  the  cervix, 


398 


The  Practice  of   Midwifery. 


crossing  the  shanks,  and  draw  the  two  Hps  together,  thus  rolling 
inward  any  intra-cervical  mucous  membrane  which  has  become 
everted. 

Differences  between  Nullijjarous  and  Parous  Uterus. — It  may  be  of 
critical  medico-legal  importance,  in  identifying  a  dead  body,  to 
determine  whether  the  woman  has  borne  children  or  not.  To 
decide  this  point,  the  examination  of  the  uterus  is  most  im- 
portant, and  such  examination  may  be  possible  when  external 
parts  are  defaced  by  decomposition.  As  a  rule  the  parous  uterus 
is  larger  than  the  nulliparous,  and  its  walls  thicker.  No  decisive 
importance    must,   however,    be    attached   to   this    sign,    since   a 


/ 


V 


Fig.  246. — Sections  of  the  nulliparous  and  parous  uterus. 


nulliparous  uterus  may  be  hypertropi)ied,  and  a  parous  uterus  may 
undergo  super-involution  until  its  walls  become  extremely  thin. 
The  most  ready  distinction  is  to  be  found  in  the  shape  of  the 
organ.  In  the  nulliparous  uterus,  the  top  of  the  fundus  externally, 
as  seen  from  the  front  or  back,  is  almost  level,  scarcely  rising 
above  the  line  of  the  broad  ligaments  ;  in  the  parous  uterus,  it  is 
markedly  convex,  rising  considerably  above  that  line  (Fig.  245, 
p.  397).  Again,  if  a  longitudinal  section  is  made  from  side  to  side, 
passing  through  the  cavity,  in  the  nulliparous  uterus,  the  walls  of 
the  body  are  seen  to  be  convex  inward,  leaving  but  a  small  cavity ; 
in  the  parous  uterus  they  are  concave  inward,  leaving  a  much 
larger  cavity  (Fig.  246). 

The  convoluted  margins  of  the  old  sinuses  of  the  placental  site, 
if  observed,  afford  absolute  evidence.     These  are  distinguishable 


Physiology  of   the   Puerperal   State.        399 

for  some  months,  and,  according  to  Sir  J.  Williams  (see  p.  389),  so 
long  as  twelve  months.  Pigmentation  at  the  placental  site  may 
also  be  observed.  The  thickened  appearance  of  the  arteries  in  the 
uterine  wall  is  a  permanent  condition  (see  p.  389). 

Most,  if  not  all,  of  these  signs,  with  the  exception  of  the  con- 
voluted walls  of  the  sinuses,  might  possibly  be  simulated  after 
the  growth  of  a  large  fibroid  tumour,  and  its  delivery  through  the 
genital  passages.  The  eversion  of  the  lips  of  the  cervix  may  result 
from  a  bilateral  incision,  sometimes  made  with  the  view  of  curing 
dysmenorrhoea. 

The  New-born  Infant. 

The  change  of  circulation  which  takes  place  immediately  after 
birth  has  already  been  described  (see  p.  123).  After  birth,  the  left 
ventricle  being  now  distended  by  blood  at  a  higher  pressure,  and 
having  harder  work  to  do,  quickly  becomes  larger  and  thicker,  in 
proportion  to  the  right,  than  it  was  during  foetal  life. 

The  rectum  soon  becomes  active,  and  expels  the  meconium,  which 
is  sterile  at  birth,  but  rapidly  becomes  infected  during  the  first  few 
days  of  life  with  numerous  organisms  partly  through  the  mouth  and 
partly  through  the  anus.  In  two  or  three  days  the  motions  assume 
the  ordinary  faecal  appearance,  becoming  yellow  instead  of  green. 
The  bowels  normally  act  at  intervals  of  a  few  hours,  the  motions 
being  soft,  of  about  the  colour  and  consistency  of  mustard.  The 
'urine  is  copious  after  the  first  few  days  of  life,  owing  to  the  liquid 
character  of  the  food,  and  has  a  specific  gravity  of  1005  to  1008. 
The  amount  of  urea  excreted  in  the  urine  increases  rapidly  from 
•06 — '11  grammes  on  the  first  day  to  "8  grammes  on  the  seventh  day.^ 
During  the  first  four  days  of  life  the  urine  also  constantly 
contains  a  small  quantity  of  albumen.  ^ 

Up  to  the  third  or  fourth  day,  when  it  obtains  for  the  first  time 
an  ample  supply  of  milk,  the  child  loses  weight.  It  regains  its 
original  weight  at  the  end  of  about  a  week,  and  from  that  time 
increases  progressively.  The  temporary  loss  may  be  as  much  as 
seven  or  eight  ounces,  and  is  certainly  dependent  upon  the 
insufficient  supply  of  food  during  the  first  few  days  of  life. 

The  remnant  of  the  umbilical  cord  dries  up  from  the  extremity 
toward  the  umbilicus,  undergoing  aseptic  necrosis,  and  a  line  of 
demarcation  is  formed  close  to  the  edge  of  the  skin,  at  which  it  is 
separated  generally  on  the  fourth  or  fifth  day,  sometimes  later.     A 

'   Housing,  Zeitschr.  f.  Geb.  u.  Gyn.,  1895,  Bd.  33,  p.  3(i. 
^  (j'/Mvny  and  Keller,  Des  Kindcscrnahrung,  1902. 


400  The  Practice  of  Midwifery. 

granulating  surface  is  left,  which  cicatrises  in  a  few  days.  The 
caput  succedaneum  generally  disappears  after  a  day  or  two,  and  in 
a  few  days,  or  within  two  weeks  at  the  utmost,  the  head  returns  to 
the  original  shape,  from  which  it  had  been  altered  by  the  moulding 
produced  in  delivery. 

For  a  week  or  more  the  skin  is  red  and  superficially  congested ; 
and  desquamation  of  the  cuticle,  generally  in  fine  flakes,  begins 
about  the  sixth  to  seventh  day,  and  continues  for  one  to  three 
weeks.  Within  the  same  time,  the  mammary  glands,  both  of  boys 
and  girls,  are  apt  to  become  red  and  swollen,  and  may  produce  a 
mucoid  secretion  containing  colostrum  bodies  and  milk  globules, 
and  rich  in  albumen  and  salts.  This  condition  is  to  be  regarded 
as  forming  a  part  of  the  cutaneous  hyperfemia.  The  slight 
inflammation  passes  off  in  a  few  days,  unless  the  glands  are 
irritated  by  manipulation. 

When  the  hypersemic  redness  of  the  skin  is  beginning  to  pass  off, 
toward  the  end  of  the  first  week,  sometimes  as  early  as  the  second 
or  third  day,  the  skin  often  becomes  coloured  yellow  by  jaundice, 
or  apparent  jaundice,  and  the  conjunctivae  partake  of  the  same  tint. 
Generally  the  appearance  of  the  faeces  is  unaltered,  the  urine  is  not 
pigmented,  and  the  infant  does  not  appear  to  suffer  much  in  health. 
The  yellow  colour  usually  subsides  and  disappears  after  about  a 
week.  There  has  been  some  doubt  whether  this  condition  is  true 
jaundice  or  not. 

There  are  probably  three  varieties  of  icterus  neonatorum  to  be 
distinguished  :  the  so-called  simple  or  idiopathic  jaundice  ;  that' 
which  follows  umbilical  infection  with  sepsis,  or  is  associated  with 
such  a  condition  as  syphilitic  or  interstitial  hepatitis  ;  and,  lastly, 
the  jaundice  associated  with  hsemoglobinuria  neonatorum,  of  which 
the  exact  nature  is  uncertain.^ 

It  is  probable  that  idiopathic  jaundice  may  be  set  up  in  some  way 
not  fully  explained,  in  connection  with  the  sudden  change  at  birth 
in  the  circulation  through  the  liver,  leading  to  slowing  of  the 
portal  circulation.^  But  the  slighter  forms  of  apparent  jaundice,  in 
which  faeces  and  urine  are  unaffected,  are  ascribed  by  some  writers 
to  changes  in  the  blood.  It  is  supposed  that  a  surplus  of  red 
corpuscles  is  broken  up  in  the  circulation,  and  that  colouring  matter 
derived  from  heematoidin  transudes  into  the  tissues.  The  yellow 
tint,  when  manifested  in  this  slighter  form,  generally  passes  off 
without  treatment  within  about  a  week. 


1  Ballantyne,  Antenatal  Pathology  :  The  Foetus,  1902,  p.  67. 

2  The  diminution  of  pressure  in  the  capillaries  of  the  liver  would  at  any  rate  diminish 
the  resistance  to  the  passage  of  secreted  bile  into  the  circulation. 


Chapter  XVIIL 

MANAGEMENT  OF   THE  PUERPERAL  STATE. 

In  the  'management  of  the  puerperal  state,  the  most  essential 
points  are  to  secure  for  the  lying-in  woman  rest,  both  bodily  and 
mental,  for  a  sufficient  period,  and  to  prevent  the  entrance  of  any 
septic  poison  by  the  most  careful  regard  for  surgical  cleanliness 
and  hygiene.  The  susceptible  condition  of  the  nervous  system 
which  exists  during  pregnancy  continues,  and  is  even  more  marked, 
during  the  puerperal  state.  It  is  important,  therefore,  to  see  that 
the  patient  is  not  excited  by  the  visits  of  friends,  or  by  too  many 
persons  in  the  room  ;  and  to  protect  her,  as  far  as  possible,  from 
any  source  of  painful  emotion. 

Cleanliness. — All  soiled  linen  and  sheets  should  be  removed 
after  delivery,  and  not  kept  in  the  room.  The  diapers  used  to 
absorb  the  lochial  discharge  should  be  changed  frequently,  before 
they  become  offensive  to  smell.  Antiseptic  wood-wool  diapers,  or 
the  "  ladies'  sanitary  towels  "  stuffed  with  absorbent  cotton,  are 
preferable  to  the  ordinary  diapers,  since  the  latter  may  not  have 
been  perfectly  purified  in  the  wash.  Sterilised  pads  of  cotton  wool 
wrapped  in  sterile  or  antiseptic  gauze,  secured  by  a  T-bandage,  are 
best  of  all,  and  should  be  used  at  any  rate  in  hospital  practice. 
Linen  and  sheets  must  be  changed  whenever  they  become  soiled. 
A  fire  in  the  room  is  useful,  for  the  sake  of  ventilation,  when  the 
weather  is  not  warm  enough  to  allow  a  window  to  be  kept  open. 
Care  should  be  taken  that  the  lying-in  room  is  not  exposed  to  foul 
air  from  a  water-closet,  or  to  access  of  sewer  gas,  or  other  septic 
exhalations.  The  room  should  be  aired  occasionally,  if  the  window 
is  not  open,  care  being  taken  to  protect  the  patient  from  draught. 
For  this  purpose  the  window  may  be  opened  for  a  minute  or  two. 
several  times  a  day,  even  in  winter,  the  patient's  head  being  covered 
meanwhile  with  a  shawl.  It  is  better  not  to  darken  the  room, 
except  when  the  patient  finds  the  light  trying,  for  light  is  healthful 
both  to  mother  and  infant.  The  external  genitals  should  be  washed 
several  times  a  day  with  an  antiseptic,  such  as  perchloride  of 
mercury  1  in  2,000,  or  lysol  in  1  per  cent,  solution.  For  this 
purpose  sponges  should  not  l>e  used,  Ijut  tampons  of  absorbent 

M.  26 


402  The  Practice  of   Midwifery. 

cotton,  which  are  afterwards  destroyed,  and  in  all  cases  the  cleansing 
should  be  done  from  before  backwards. 

After  labour  in  a  normal  case  the  genital  canal  may  be  regarded 
as  free  from  all  pathogenic  organisms,  and  it  should  be  the  constant 
endeavour  of  the  nurse  to  keep  it  so.  No  manipulation  of  any  kind 
must  be  carried  out  by  the  nurse  about  the  genitalia  without  a 
preliminary  scrubbing  of  her  hands  with  soap  and  water  and  soak- 
ing them  for  a  sufficient  length  of  time  in  an  efficient  antiseptic 
solution. 

The  triumph  of  antisepsis  in  lying-in  hospitals  was  at  first 
obtained  by  the  routine  use  of  mercurial  douches  1  in  2,000  during 
the  puerperal  period,  in  addition  to  the  employment  of  mercury 
as  an  antiseptic  for  hands.  The  recent  tendency  in  them,  however, 
is  to  discard  douches  in  normal  cases  ;  but  other  precautions  have 
been  substituted.  Thus  at  the  Maternity  Hospital  of  New  York 
douches  of  cyllin  emulsion  1  per  cent,  are  used  before  delivery. 
The  genitals  are  washed  with  the  same  after  delivery,  and  an 
occlusion  bandage  is  then  applied  containing  a  pad  wrung  out  of 
the  same  cyllin  emulsion.  This  is  changed  every  two  hours,  or 
whenever  the  i>atient  passes  urine. 

In  private  practice,  routine  douches  in  normal  cases  have  been 
almost  completely  abandoned,  since,  if  the  nurse  is  not  very  careful  in 
her  antisepsis,  septic  infection  may  be  introduced  by  means  of  the 
douche.  They  may  be  called  for  if  the  lochial  discharge  becomes 
offensive.  The  antiseptic  should  be  an  efficient  one,  not  too  diluted ; 
and,  as  an  additional  security,  the  water  should  in  all  cases  be 
sterilised  by  boiling.  If  used  at  all,  the  irrigation  should  be  used  regu- 
larly at  least  twice  a  day.  Otherwise  the  vaginal  tube  may  rub  off 
some  granulations,  and  leave  a  spot  more  prone  to  the  absorption  of 
the  septic  material  allowed  afterwards  to  form. 

For  use  in  private  practice,  a  solution  of  chinosol  1  in  400  to  600 
appears  to  be  an  efficient  non-j)oisonous  antiseptic.  Iodide  or 
perchloride  of  mercury  1  in  4,000  may,  however,  be  used  without 
risk  of  producing  poisonous  effects,  provided  that  the  nurse  is 
skilled  and  that  care  is  taken  that  no  excess  remains  in  the  vagina. 
The  iodide  is  reputed  more  highly  antiseptic  and  less  poisonous 
than  the  perchloride,  but  it  more  often  causes  irritation  to  the 
vagina.  Cyllin  1  in  200  to  400,  lysol  1  per  cent.,  and  tincture  of 
iodine  5i. — ij.  ad  Oj.,  are  also  good  antiseptics. 

The  syringing  may  be  carried  out  by  a  douche  can  or  by  an 
irrigator,  a  round  bed -pan,  or,  better  still,  a  "  ladies'  bed-bath," 
being  placed  under  the  patient's  hips.  The  douche  can  should  be 
placed  but  a  few  feet  above  the  level  of  the  patient's  body,  and  to 


Management  of  the   Puerperal  State.       403 

avoid  the  entrance  of  air  into  the  vagina  a  Httle  of  the  fluid  should 
be  allowed  to  run  through  the  vaginal  tube  before  it  is  introduced. 
Great  care  must  be  taken  to  cleanse  efficiently  the  vulva  })efore  the 
douche  is  given.  The  vaginal  tube  should  be  of  glass,  and  should 
be  sterilised  by  boiling,  or  immersion  in  perchloride  of  mercury 
1  in  1,000. 

Diet  and  General  Management — Immediately  after  labom%  it 
is  a  good  plan  to  give  some  liquid  nourishment,  such  as  beef-tea, 
or  an  egg  beaten  up  in  hot  milk.  After  the  baby  has  been  washed 
and  dressed,  and  soiled  linen  removed,  the  patient  should  be  allowed 
to  sleep.  If  labour  has  been  unusually  severe,  and  the  patient  is 
restless,  an  opiate  may  be  given,  but  it  is  preferable  not  to  give  one 
as  a  general  rule.  If  after-pains  are  unusually  troublesome,  a  few 
half-drachm  doses  of  ergot  repeated  every  four  hours  with  or  without 
a  mild  anodyne,^  rather  than  opium  or  morjDhia,  are  generally 
sufficient  to  meet  the  case.  It  was  formerly  the  custom  to  keep 
lying-in  patients  on  low  diet,  with  the  idea  that  such  a  regimen  was 
antiphlogistic.  It  is  now  agreed  that  the  better  they  are  nourished 
the  more  likely  they  are  to  resist  disease.  Frequently  women  do 
not  care  for  meat,  or  for  much  solid  food,  for  the  first  two  or  three 
days,  and,  in  that  case,  there  is  no  advantage  in  pressing  the 
appetite.  They  should  then  have  nourishing  food  in  a  digestible 
form,  a  fair  allowance  of  milk  in  some  shape,  as  well  as  soup  or  beef- 
tea,  tea  or  coffee  with  toast  or  bread-and-butter,  eggs,  or  milk  gruel, 
according  to  taste.  There  is,  however,  no  harm  in  giving  fish, 
chicken,  or  digestible  meat  even  before  the  third  day,  if  the  patient 
likes  it,  and  in  the  absence  of  any  rise  of  temperature  or  constitu- 
tional disturbance  of  any  kind.  After  this  time,  in  the  absence  of 
febrile  disturbance,  she  may  take  ordinary  simple  diet  in  reasonable 
quantity,  allowance  being  made  for  the  fact  of  her  being  quiet  in 
bed,  and,  on  the  other  hand,  for  the  material  required  for  lactation. 
In  the  absence  of  lactation,  less  ample  diet  is  required. 

The  physician  should  visit  the  patient  within  twelve  hours  after 
delivery,  and  daily  for  the  first  week.  He  should  note  pulse  and 
temperature  at  each  visit,  unless  there  is  a  nurse  who  is  able  to 
record  these  night  and  morning.  The  first  signal  of  any  disturb- 
ance will  often  be  given  by  a  rise  of  temperature.  At  the  first 
visit  he  should  inquire  whether  urine  has  been  passed,  and,  if  the 
quantity  passed  is  very  little,  he  should  make  sure,  by  abdominal 
palpation,  whether  there  is  any  distension  of  bladder.     In  case  of 

'  The  following  is  a  useful  formula  : — Potass.  Bromicl.,  gr.  x. ;  Tirict.  Hyoscyaini,  ss.  ; 
Sp.  Carnphora!,  rr^  xv.  ;  Mucilag.  Aeaciie,  5j.  ;  Aq.,  ad  Jj.  ;  to  be  taken  occasionally, 

26—2 


404  The   Practice  of   Midwifery. 

retention,  the  catheter  must  be  used  at  least  twice  a  day.  To 
prevent  the  setting  up  of  cystitis  by  carrying  septic  matter  into  the 
bladder,  the  patient  should  be  placed  in  the  left  lateral  position, 
the  lochia  should,  just  before  the  introduction  of  the  catheter,  be 
washed  away  from  the  vulva  by  an  antiseptic  solution,  such  as 
mercuric  iodide  1  in  4,000,  and  the  catheter,  washed  in  a  solution 
of  perchloride  or  iodide  of  mercury  1  in  1,000,  and  anointed  with 
an  antiseptic  lubricant,  such  as  lano-cyllin  or  perchloride  of 
mercury  1  in  1,000  glycerine,  should  be  passed  into  the  urethra  by 
sight,  A  glass  catheter,  which  can  be  sterilised  by  boiling  water, 
is  the  safest  to  use,  care  being  taken  to  push  it  only  just  far  enough 
into  the  bladder  to  allow  the  urine  to  flow.  For  the  first  twelve 
hours  at  any  rate,  the  urine  must  be  passed  in  a  horizontal  position 
over  a  bed-pan,  and  this  position  is  often  a  chief  cause  of  the 
difficulty.  After  that  time,  if  there  is  no  excessive  sanguineous 
discharge,  the  patient  may,  if  necessary;  be  allowed  to  kneel  up  to 
pass  her  urine,  or  to  sit  up  on  the  bed-bath,  or  turn  over  on  to  her 
face.  For  it  is  always  desirable  to  avoid  the  use  of  a  catheter  if 
possible.  She  should  be  encouraged  to  vary  her  position  in  bed 
from  time  to  time.  If  she  lies  constantly  on  her  back,  the  lochial 
discharge  is  dammed  up  in  the  vagina  by  the  perineum ;  if  she  is 
always  on  one  side,  it  may  be  retained  in  the  uterus,  the  fundus 
bagging  over  to  the  dependent  side.  The  kneeling  up  to  pass 
urine,  after  the  time  has  passed  when  it  would  cause  risk  of 
haemorrhage,  has  the  advantage  that  it  assists  the  escape  of  the 
discharge.  With  the  same  object,  after  the  first  day  or  two,  if 
the  patient  is  doing  well,  she  may  be  supported  in  a  sitting 
position  to  take  her  meals.  She  should  also  be  in  the  sitting 
posture,  or  have  the  shoulders  supported  by  pillows,  to  give  the 
infant  the  breast.  These  expedients  are  more  called  for  when  the 
plan  of  vaginal  irrigation  is  not  employed.  So  long  as  the  patient 
is  doing  well,  it  is  not  desirable  to  make  vaginal  examinations.  If 
there  is  occasion  for  doing  so,  the  hand  must  be  well  washed  with 
soap  and  water  and  then  disinfected  in  the  usual  manner  with 
spirit  and  a  solution  of  perchloride  of  mercury  1  in  1,000. 

To  obtain  early  warning  of  any  septic  or  inflammatory  mischief, 
it  is  desirable  not  only  to  keep  a  record  of  temperature,  taken  at 
least  twice  a  day,  but  to  record  the  progress  of  involution,  as  indi- 
cated by  the  height  of  the  fundus  above  the  symphysis  pubis. 
Bladder  and,  if  possible,  rectum  should  be  empty  when  the  obser- 
vation is  taken.     A  convenient  mode^  is  to  record  the  height  of 

1  "  Notes  on  the  Variation  in  the  Height  of  the  Fundus  Uteri  during  the  Puer- 
perium,"  Stevens  and  Griffith,  Trans.  Obst.  Soc.  London,  1895,  Vol.  XXXVII.,  p.  2i6. 


Management  of  the   Puerperal   wState.       405 

the  fundus  on  the  temperature  chart,  taking  the  line  representing 
each  degree  of  temperature  above  lOO'^  as  representing  also  each 
inch  above  the  i3ubes.    Examples  of  this  are  shown  in  Figs.  247,  248. 


M'EM'EM-EM-EM-EM-EM- EM-EM- EM-  E  M- EM-EM- E.M-E 


99° 
NORMAL 


Fig.  247. — Chart  showing  involution  of   uterus.     Average  of  thirty-four   cases. 
(After  Stevens  and  Griffith.) 


Fig.  248. — Chart  showing  involution  of  uteius.     Saprsemia.     Effect  of  one  douche, 
and  clearing  out  uterus.     (After  Stevens  and  Griffith.) 


Fig,  247  shows  the  curve  obtained  from  an  average  of  thirty-four 
cases  ;  Fig.  248  illustrates  the  effect  of  saprremia  in  checking  in- 
volution, and  the  result  of  one  douche  and  clearing  out  uterus. 

If  possible,  the  patient  should  keep  her  bed  for  ten  days,  or  for  a 
longer  time,  if  the  discharge  is  still  sanguineous,  and  she  should 


4o6  The  Practice  of   Midwifery. 

return  to  it,  if  getting  up  brings  on  again  a  red  discharge.  On  first 
leaving  it,  she  should  spend  much  of  her  time  reclining  on  a  sofa, 
and  should  not  return  completely  to  her  ordinary  mode  of  life,  or 
undertake  severe  exertion,  till  the  end  of  six  weeks,  at  which  time 
involution  ought  to  be  fairly  complete.  In  the  case  of  a  primipara, 
when  there  has  been  much  laceration,  or  bursting  of  soft  parts,  it  is 
often  desirable  for  the  recumbent  position  to  be  maintained,  for  the 
most  part,  for  three  or  even  four  weeks. 

Action  of  the  Bowels. — It  is  usual  to  secure  an  action  of  the 
bowels  on  the  second  or  third  day,  and  it  is  not  desirable  to  leave 
them  confined  longer  than  this.  If  the  patient  does  not  dislike  it, 
and  the  nurse  is  skilful,  a  copious  enema  of  soap  and  water  avoids 
the  necessity  of  an  aperient.  Otherwise  a  mild  laxative  may  be 
given.  The  traditional  castor-oil  is  often  disliked.  If  not,  it  may 
be  given  in  a  dose  of  two  to  four  drachms.  Or  its  place  may  be 
taken  by  the  compound  liquorice  powder,  or  tamar  indien,  or  the 
following  pill: — Ext.  Aloes  Socot.,  gr.  f ;  Ext.  Nucis  Vomicae,  gr.  ss.; 
Ext.  Hyoscyami,  gr.  iij.;  Pulv.  Glycyrrhiz.,  q.s. 

Lactation. — Not  only  does  the  infant  thrive  better  when  suckled 
than  when  fed  artificially,  but  it  is  most  important  for  the  mother 
herself  to  suckle  at  least  until  the  completion  of  involution,  that 
she  may  not  lose  the  stimulus  to  tbe  contraction  and  involution  of 
the  uterus  associated  with  the  performance  of  tbat  function.  Even 
if  the  milk  is  deficient  in  quantity  or  poor  in  quality,  she  should  at 
least  partially  nurse  her  infant  for  the  first  four  or  six  weeks,  if  no 
longer.  The  chief  causes  which  should  prevent  this  are  entire 
absence  of  milk,  or  nipples  which  are  useless  for  suckling  either 
from  flattening,  want  of  development,  or  cracks  which  render 
suckling  too  painful,  or  the  occurrence  of  acute  mastitis.  Lactation 
should  not  be  continued  after  the  puerperal  period,  either  if  the 
milk  is  poor  in  quality,  so  that  the  child  does  not  thrive  upon  it,  or 
if  the  mother's  health  is  so  delicate  that  injury  to  her  from  it  is  to 
be  feared,  especially  if  she  has  a  tendency  to  phthisis,  or  belongs 
to  a  strongly  phthisical  family.  Suckling  must  be  prohibited  if  the 
mother  is  suffering  from  any  acute  illness,  and  in  certain  cases  of 
mal-development,  such  as  cleft  palate  or  hare-lip,  the  child  may  be 
unable  to  suck. 

The  child  should  be  put  to  the  breast  for  the  first  time  within 
twelve  hours  after  delivery,  when  the  mother  has  had  some  sleep. 
For  the  first  two  days  suckling  should  be  repeated  only  two  or 
three  times  a  day.     As  soon  as  the  milk  is  freely  secreted,  about 


Management  of  the   Puerperal   State.      407 

the  third  day,  the  infant  should  be  accustomed  to  take  the  breast  at 
regular  intervals  of  about  two  hours,  a  httle  later  at  three  hours' 
interval,  and  afterwards  four  hours.  During  the  night  it  may  be 
allowed  to  sleep  as  long  as  it  will,  so  that,  if  possible,  the  mother 
may  not  be  disturbed  more  than  once.  Eight  or  nine  feedings  at 
first  in  the  twenty-four  hours  are  usually  sufficient.  No  other 
food  is  generally  necessary  before  the  secretion  of  milk,  but  if  the 
infant  appears  hungry,  a  few  teaspoonfuls  of  water  and  sugar  or 
milk  and  water,  one  of  the  former  to  three  or  four  parts  of  the 
latter,  may  be  given  ;  or,  if  sterilised,  cows'  milk  may  be  given 
undiluted. 

The  duration  of  each  feeding  may  vary  from  five  to  twenty  minutes, 
according  to  the  strength  of  the  child  and  the  ease  with  which  it  can 
obtain  the  milk.  About  ten  minutes  is  an  average.  If  the  milk 
is  vomited  or  curds  appear  in  the  stools,  it  is  generally  a  sign  that 
the  child  is  taking  more  than  it  requires  or  can  digest. 

The  child  should  be  weighed  at  least  twice  a  week.  It  should 
regain  its  birth  weight  in  ten  days,  and  afterwards  gain  about  five 
ounces  a  week  for  the  first  two  or  three  months. 

The  child  should  lie  in  a  bassinette,  and  not  in  the  bed  with  its 
mother.  It  should  never  be  allowed  to  go  to  sleep  with  the  nipj)le 
in  its  mouth.  After  suckling,  the  nipples  should  be  washed, 
carefully  dried,  and  anointed  with  glycerine  of  borax.  This  does 
much  to  prevent  their  becoming  cracked.  The  child's  mouth  should 
also  be  washed  out  with  a  piece  of  linen  rag  dijDped  in  clean  boiled 
water.  By  this  means  the  production  of  thrush,  by  the  growth  of 
a  fungus,  o'idium  albicans,  in  the  mouth,  is  prevented.  It  is  a  good 
plan  to  wash  the  nipples  before  the  suckling  as  well  as  afterc 
Both  breasts  should  be  used  at  each  time  of  nursing,  that  the 
tension  may  be  equally  relieved,  if  both  are  tense  ;  otherwise  they 
may  be  used  alternately.  Primiparse  may  require  instruction  in  the 
mode  of  supporting  the  infant  on  the  arm  in  a  nearly  horizontal 
position,  and  adjusting  the  nipple,  so  that  the  nostrils  are  not 
obstructed  by  pressing  against  the  breast,  but  are  free  for  breathing. 
It  may  be  necessary  for  the  mother  to  press  down  the  areola  by  one 
finger  placed  above,  the  other  below  it,  especially  if  the  breast  is 
tense  or  the  nipple  flattened. 

The  breast  may  become  knotty  and  painful,  when  the  milk  is  first 
secreted,  from  the  secretion  not  escaping  freely  through  the  ducts. 
Gentle  friction  in  the  direction  of  the  nipple  is  then  useful,  and,  if 
the  infant  is  not  able  to  suck  strongly,  it  may  be  desirable  to  draw 
a  little  milk  with  a  breast  glass,  fitted  with  elastic  tube  and  mouth- 
piece.    If,  however,  suckling  is  not  intended,  and  the  milk  is  to  be 


4o8  The  Practice  of   Midwifery. 

suppressed,  all  friction  or  drawing  of  the  breasts  should  be  avoided. 
The  breasts  should  be  supported,  if  swollen  and  tender,  and  gentle 
pressure  made  upon  them.  This  may  be  done  by  covering  each 
breast  with  a  thin  layer  of  cotton  wool,  and  compressing  it  with  two 
large  handkerchiefs,  one  tied  above  the  opposite  shoulder,  the  other 
below  the  opposite  armpit ;  or  both  breasts  may  be  supported  and 
gently  compressed  by  a  carefully  adjusted  bandage,  the  nipples 
being  left  free,  or  a  muslin  binder  padded  with  wool  may  be  applied 
round  the  chest.  This  is  often  the  most  comfortable  support.  At  the 
same  time  the  woman  should  drink  little,  and  the  bowels  should  be 
kept  acting  freely  by  a  saline  laxative,  such  as  sulphate  of  magnesia. 
If  necessary,  belladonna  may  be  used  for  its  local  influence  in 
checking  the  secretion  of  milk,  or  may  be  given  internally.  The 
best  method  is  to  smear  the  breasts  with  glycerine  of  belladonna  ^ 
or  to  apply  an  evaporating  lotion  containing  belladonna.^  Iodide  of 
potassium,  which  has  a  specific  action  in  checking  the  gland  activity, 
may  also  be  given  in  twenty-grain  doses,  three  or  four  times 
repeated. 

If  the  mother's  milk  is  insufficient  in  quantity,  1,000  to  1,200 
grammes,  35  to  42  ounces — being  the  average  amount  secreted  daily, 
she  should  suckle  at  longer  intervals,  and  the  breast  should  be  supple- 
mented by  cows'  milk  suitably  diluted,  or  sterilised,  and  given  by 
the  bottle.  This  plan  is  much  better  for  the  infant  than  an 
entirely  artificial  diet,  although  with  the  lower  classes  it  is  often 
necessary  to  combat  a  prejudice  against  "  mixing  the  milks."  If, 
on  the  contrary,  the  milk  is  excessive,  the  mother  should  drink 
less  liquid,  and  the  bowels  should  be  kept  acting  freely.  It  is 
rarely  necessary  to  draw  off  the  excess  with  a  breast-glass,  as  the 
milk  usually  runs  away  spontaneously. 

The  only  mode  of  maintaining  or  increasing  the  secretion  of  milk 
is  to  give  a  diet  with  plenty  of  liquid,  and  a  reasonable  abundance 
of  nitrogenous  food,  especially  meat,  fish,  and  vegetable  food 
containing  much  nitrogen,  such  as  lentils,  beans,  or  peas.  A 
moderate  quantity  of  stout  or  beer  is  advantageous  if  it  does  not 
disagree.  The  so-called  galactagogues  (such  as  castor-oil  leaves 
locally  apj)lied)  are  not  to  be  relied  upon.  Pilocarpine  in  small 
doses  is  reputed  to  be  the  most  efficient. 

Management  of  the  New-born  Infant. — As  soon  after  delivery 
as  the  nurse's  attention  is  no  longer  required  for  the  mother,  she 
washes  and  dresses  the  child,  which  has  meanwhile  been  covered  up 

1  Ext.  Belladonnse,  gr.  Ix.  ;  Glycerini,  §j. 

2  Lin.  BelladonDfe,  3iv.  ;  Lin.  Aconiti,  3ij.  ;  Spt.  Vini  Eectif.,  3iv. ;  Aq.  RosfB,  Jx, 


Management  of  the   Puerperal   State.       409 

in  a  piece  of  flannel.  Before  or  affcer  the  bath  the  medical  attendant 
should  carefully  examine  the  baby  so  as  to  make  sure  that  it  has  no 
defect  or  malformation  such  as  supernumerary  digits,  imperforate 
anus,  or  cleft  palate.  To  bathe  it,  the  nurse  places  the  baby  in  a 
warm  bath,  and  washes  it  all  over  with  soap  and  water.  First  of 
all  the  eyes,  and  their  neighbourhood,  which  have  already  been 
wiped  clean  from  mucus,  should  be  carefully  cleansed  by  means  of 
a  piece  of  soft  linen  rag  dipped  in  clean  water  or,  better,  boric  acid 
lotion.  If  the  vernix  caseosa  be  unusually  adherent,  it  may  be 
softened  by  smearing  cold  cream  or  olive  oil  over  it,  but  too  much 
friction  in  removing  it  should  be  avoided.  The  mode  of  treating 
the  funis  traditional  with  nurses  is  to  wrap  it  in  a  piece  of  linen  in 
which  a  hole  has  been  burnt,  through  which  to  pass  the  funis,  and 
to  change  the  piece  of  linen  daily.  It  is  preferable  to  wrap  it  in  a 
piece  of  absorbent  gauze,  several  layers  together,  or  in  absorbent 
cotton,  after  dusting  it  with  boric  acid  powder.  The  funis  is  then 
turned  upward  on  the  abdomen,  and  kept  in  place  by  a  binder,  which 
should  not  be  too  tight.  After  the  funis  has  dropped  off,  a  small 
flat  pad  of  dry  linen  or  boric  lint  should  be  j)laced  over  the  umbilicus 
until  it  has  completely  cicatrised. 

The  clothing  of  the  infant  should  be  warm,  but  not  tight  enough 
to  compress  thorax  or  abdomen,  or  interfere  with  the  movement  of 
the  limbs.  A  diaper  folded  in  a  triangular  shape  is  used.  The 
anterior  corner  is  brought  up  between  the  thighs  over  the  abdomen, 
and  kept  in  place  by  tbe  lateral  corners  tied  across  it ;  no  pins 
should  be  used  about  the  baby.  To  prevent  excoriation  of  the  skin, 
it  is  of  great  importance  to  change  the  diaj^ers  as  soon  as  they  are 
wetted  or  soiled,  and  to  cleanse  and  dry  the  buttocks.  The  child 
will  generally  give  notice  by  crying  when  it  has  passed  any  evacua- 
tions. The  child  should  be  washed  in  a  warm  bath  every  day,  and, 
after  the  first  few  weeks,  morning  and  evening.  The  flexures  should 
be  thoroughly  dried  after  washing,  and  dusted  with  pure  starch 
powder.  For  the  comfort  of  the  mother  it  is  desirable  to  accustom 
the  infant,  from  the  first,  to  go  to  sleep,  laid  quietly  in  its  cradle, 
without  nursing  or  rocking  to  sleep. 

Selection  of  a  Wet-nurse.— When  a  mother  is  unable  or 
unwilling  to  nurse,  nourishment  by  a  wet-nurse  is  undoubtedly 
more  favourable  for  the  child  than  bottle-feeding,  as  ordinarily 
carried  out.  With  a  patient  of  the  upper  classes,  therefore,  this 
alternative  may  be  recommended  ;  but  the  necessity  for  it  is,  to, a 
great  extent,  done  away  with  where  humanised  milk,  or  the  specially 
prepared  "  modified  milk,"  can  be  procured. 


4IO 


The   Practice  of   Midwifery. 


The  wet-nurse  should  have  the  appearance  of  good  health,  and 
be  free  from  any  sign  or  suspicion  of  syphilis,  scrofula,  or  tuber- 
culosis. She  should  also  have  sound,  well-developed  nipples, 
well-developed  breasts,  not  too  fat,  and  the  milk  should  flow  from 
them  easily.  The  best  age  is  between  20  and  35.  It  is  preferable 
that  the  age  of  her  infant  should  not  be  too  far  removed  from  that 
of  the  one  to  be  nursed,  but  it  should  be  older  rather  than  younger. 
The  best  test  of  the  quality  of  her  milk  is  the  condition  of  her  own 
infant.  This  should  also  be  inspected  most  carefully,  especially 
about  the  buttocks,  to  make  sure  that  there  is  no  eruption  or  other 
sign  suggesting  any  possibility  of  syphilitic  taint.  If  the  milk  is 
specially  examined,  it  should  have  a  specific  gravity  of  about  1030, 
give  a  percentage  of  cream  as  much  as  3  per  cent,  by  lactometer, 
and  under  the  microscope  show  abundant  milk  globules,  no  colos- 
trum corpuscles.  If  the  infant,  after  fair  trial,  does  not  thrive  with 
one  wet-nurse,  it  may  be  necessary  to  change  her  for  another. 

The  diet  of  the  wet-nurse  and  amount  of  exercise  taken  should 
be,  as  far  as  possible,  what  she  has  been  accustomed  to.  If  she 
is  put  upon  an  unnecessarily  rich  diet,  and  leads  a  more  inactive 
life  than  before,  the  milk  is  apt  to  fail.  Two  meals  of  meat  in  the 
day,  and  about  a  pint  of  stout  or  beer,  if  she  is  accustomed  to  take 
alcohol,  may  be  given. 

Artificial  Feeding. — A  large  part  of  the  mortality  of  hand-fed 
children  in  the  lower  classes  is  due  to  the  fact  that  farinaceous 
food  is  frequently  given  within  the  first  few  months,  at  a  time 
when,  from  the  imj)erfect  development  of  the  salivary  glands,  the 
infant  has  little  or  no  power  of  digesting  starch.  In  general,  only 
milk  should  be  given  for  the  first  six  months.  Goats'  milk  and 
asses'  milk  both  have  an  advantage  over  cows'  milk  in  a  closer 
resemblance  to  human  milk.  In  general,  however,  cows'  milk  will 
be  the  only  substitute  available.  The  object,  of  course,  is  to  make 
the  substitute  resemble  human  milk  as  closely  as  possible.  The 
following  table  gives  the  average  percentage  of  constituents  in 
each : — 


Hnman. 

Cows'. 

Goats'. 

Asses'. 

Water 

87-0 

85-7 

86-3 

89-3 

Solids 

12-9 

14-3 

13-7 

10-7 

Casein 

1-9 

4-8 

3-4 

1-09 

Lactalbumen 

0-4 

0-57 

1-3 

0-7 

Fat 

4-0 

4-3 

4-3 

3-0 

Lactose         .... 

6-3 

4-03 

4-0 

5-5 

Salts 

0-34 

0-5 

0-62 

0-42 

Management  of  the   Puerperal   State.      411 

The  proportions  in  human  milk,  however,  vary  considerably, 
especially  that  of  proteids.  Thus  the  percentage  of  proteids  given 
by  different  authorities  varies  as  widely  as  from  1*5  to  3*9.  More 
observations  are  required  on  the  relative  proportion  of  caseinogen 
and  lactalbumen  in  human  milk.  The  proteid  coagulable  by  acid 
is  present  in  cows'  milk  in  great  excess  as  compared  with  the 
uncoagulable  proteid,  while  in  human  milk  there  is  also  more 
coagulable  than  non-coagulable  proteid,  but  not  to  the  same 
excess. 

Human  milk  is  alkaline  in  reaction  and  usually  sterile ;  cows' 
milk  when  it  reaches  the  consumer  is  generally  acid,  and  contains 
many  organisms.  The  percentage  of  nutrient  materials  is  about 
12"9  in  human  milk  and  14"3  in  cows'  milk.  If  water  equal 
to  two-thirds  of  the  milk  be  added  to  cows'  milk,  the  j^roportion  of 
proteids  will  be  about  right,  but  the  milk  will  be  poor  in  cream  and 
sugar.  This  defect  can,  however,  be  readily  remedied  by  the  addition 
of  sugar  of  milk  and  cream.  The  chief  difficulty,  however,  is  in  the 
digestion  of  the  casein,  and  arises  from  the  fact  that  the  casein  of 
cows'  milk  coagulates  in  larger,  firmer  curds,  which  are  more  diffi- 
cult of  digestion  than  the  flocculi  of  human  milk.  Practically, 
therefore,  it  is  necessary  to  add  an  equal  part  of  water,  provided 
that  the  milk  has  not  been  previously  watered,  for  infants  under 
three  months,  and  two  parts  of  water  for  infants  under  one  month, 
together  with  twenty  to  thirty  drops  of  nursery  cream,  if  it  can  be 
obtained  pure  from  a  reliable  source,  and  one  teaspoonful  of  sugar 
of  milk  to  each  feed.  The  digestion  of  the  casein  is  the  chief  point 
to  be  attended  to.  If  undigested  curds  are  vomited  or  seen  in  the 
faeces,  the  milk  must  be  more  diluted.  It  is  a  common  mistake, 
however,  with  nurses  to  dilute  the  milk  too  much  and  too  long, 
After  three  months  the  proportion  of  water  may  generally  be 
reduced  to  half  the  milk,  after  four  to  one-third,  and  from  the  fifth 
or  sixth  onward  the  milk  may  be  given  undiluted. 

The  water  for  dilution  should  be  boiled.  It  is  still  better  to  use 
very  thin  barley  water  or  decoction  of  arrowroot  (53.  ad  Oj.) ;  this 
prevents  the  curds  formed  from  being  so  large.  This  plan  may, 
therefore,  be  adopted,  if  undigested  curds  are  seen.  It  is  preferable 
to  sterilise  the  milk  itself  by  heating  it  to  the  boiling  point,  and 
then  cooling  it  rapidly,  or,  better,  by  heating  it  in  a  proper  milk 
steriliser.  This  is  the  more  desirable  in  towns  where  the  milk 
cannot  be  got  perfectly  fresh. 

According  to  the  researches  of  Budin,  it  is  best,  if  the  milk  is 
efficiently  sterilised,  to  give  it  undiluted.  It  is  found  that,  with 
sterilised  milk,  hard  curds  are  not   formed  in  the   stomach,  and 


412 


The  Practice  of   Midwifery. 


experiments  show  that  the  infants  gam  weight  more  rapidly  on 
undikited  than  on  diUited  milk.  A  convenient  form  of  milk  steriliser 
is  shown  in  Fig.  249.  The  boiling  pan  holds  seven  bottles,  each 
containing  a  measure  of  food,  and  fitted  with  a  valvular  cap,  which 
allows  steam  to  escape,  but  prevents  the  entrance  of  air.  The  water 
is  to  be  kept  at  the  boiling  point  for  forty  minutes.  A  supply  suffi- 
cient for  twenty-four  hours  is  thus  prepared.  When  the  food  is 
required,  a  bottle  is  heated  in  the  food  warmer,  till  the  thermometer 
marks  100°.  The  rubber  cap  is  then  taken  off  and  replaced  by  a 
soft  rubber  nipple,  and  the  bottle  is  at  once  given  to  the  child. 
Milk  sterilised  in   this  way   is   found   not   to   have    suffered   the 

diminution  of  digestibility  which  is 
noticed  in  boiled  milk. 

Another  plan  is  not  absolutely  to 
sterilise,  but  to  "  pasteurise,"  the 
milk,  by  keeping  it  for  at  least 
twenty  minutes  at  a  temperature  of 
150°  to  160°.  Hawksley's  steriliser 
may  be  used  in  this  way,  and  the 
same  object  is  more  easily  attained 
by  Aymard's  steriliser.  The  chief 
advantages  of  pasteurisation  are  that 
chemically  the  milk  is  not  seriously 
changed,  the  taste  and  smell  are 
unaltered,  any  pathogenic  organisms 
present  are  destroyed,  fermentation 
is  stopped,  and  the  risk  of  the 
transmission  of  infectious  disease 
is  abolished.^ 

Sterilisation  of  milk  does  not 
obviate  the  necessity  that  the  milk  should  be  as  fresh  and  uncon- 
taminated  as  jDOSsible  before  sterilisation.  Scurvy  sometimes 
occurs  in  infants  fed  on  sterilised  or  peptonised  milk,  and  may 
be  due,  as  some  authorities  maintain,  to  the  presence  of  bacterial 
toxins  in  the  milk  before  sterilisation,  or  to  the  destruction  of 
the  antiscorbutic  element  in  fresh  milk  by  its  pe^Dtonisation  or 
sterilisation. 

The  proper  proportion  of  sugar  to  add  is  about  sixty  grains  to 
four  ounces  of  diluted  milk.  Milk  sugar  is  of  course  the  best,  but 
in  the  absence  of  it,  ordinary  white  sugar  may  be  added.  Practi- 
cally a  small  lump  may  be  dissolved  in  each  bottle  of  milk.     The 


Fig.   249.— Hawksleys    Milk 
Steriliser. 


1  Cautley,  The  Feeding  of  Infants,  p.  199 


Management  of  the  Puerperal  State.       413 

milk  should  be  given  warm,  at  a  temperature  of  about  98"^  F.  A 
young  infant  will  not  require  more  than  from  one  to  two  ounces 
at  a  time.  If  cream  be  added  it  must  be  quite  fresh  and  contain  no 
preservatives.  It  is  possible  now  to  obtain  nursery  cream  of  good 
quality  and  proper  consistence  from  any  of  the  large  dairy  com- 
panies. In  hot  weather  both  the  cream  and  the  milk  should  be 
either  pasteurised  or  raised  to  the  boiling  point,  "  scalded,"  as 
soon  as  they  are  received ;  and  when  the  milk  has  been  boiled 
care  must  be  taken  to  keep  it  in  a  tightly  sealed-up  vessel  in  a 
cool  place. 

It  is  often  recommended  that  the  milk  should  be  from  one  cow. 
On  the  other  hand,  it  is  stated  that  the  cow  is  liable  to  periods 
of  heat  even  during  lactation,  and  that  then  the  milk  is  apt  to 
disagree,  whereas  the  effect  is  not  noticed  when  the  milk  of  a  dairy 
is  all  mixed.  In  towns  it  obviously  requires  much  faith  to  believe 
that  milk  from  one  cow  is  really  obtained. 

Condensed  milk,  diluted  with  water,  has  the  advantage  that  the 
casein  does  not  clot  in  such  large  curds  as  that  of  fresh  milk.  It 
sometimes  agrees  better  therefore  for  a  time  when  the  infant  does 
not  digest  the  casein.  It  has  a  great  disadvantage,  however,  of 
containing  much  too  large  a  proportion  of  sugar.  Its  prolonged 
use  seems  inadvisable  on  this  account,  and,  though  fattening, 
it  appears  to  tend  towards  the  production  of  rickets.  Unsweetened 
condensed  milk,  which  may  now  be  obtained,  is  preferable,  but 
will  only  keep  about  a  day  after  the  opening  of  the  tin.  With 
this  a  little  sugar  should  be  added  at  the  time  of  use.  It  is  still 
commoner  with  condensed  than  with  fresh  milk  to  make  the 
mixture  too  weak.  Four  parts  of  water  to  one  of  milk  make  it 
equal  in  strength  to  fresh  milk,  not  reckonin;^  the  added  sugar. 
For  the  infant's  use,  therefore,  not  more  than  about  nine  or  ten 
parts  of  water  should  generally  be  added,  except  for  the  first  three 
or  four  weeks,  when  it  may  be  necessary  to  add  as  much  as  fourteen 
or  fifteen  parts. 

"  Humanised  milk  "  is  now  made  by  some  of  the  dairy  companies 
from  cows'  milk,  by  the  addition  of  cream,  freshly  prepared  whey, 
and  milk  sugar.  This  may  be  used  with  advantage,  where  it  can 
be  obtained,  and  is  generally  sent  out  sterilised,  or  it  can  be 
sterilised  in  the  same  way  as  ordinary  milk,  in  the  milk  steriliser. 
If  pure  cows'  milk  can  be  obtained,  a  close  approximation  to  human 
milk  will  be  given  by  the  following  plan.  Add  to  the  milk  two- 
thirds  its  bulk  of  water,  and  to  each  four  ounces  of  the  mixture 
add  sixty  grains  of  milk  sugar,  and  two  teaspoonfuls  of  cream. 
The  whole  is  then  to  be  heated  in   the  steriliser.     The  liest  cream 


414 


The   Practice  of   Midwifery. 


is  that  obtained  in  the  centrifugal  separator,  not  by  skimming,  so 
that  it  may  be  supplied  fresher. 

An  improvement  in  infant  feeding  is  the  introduction  of  milk 
laboratories,  the  first  of  which  was  instituted  at  Boston,  U.S.A., 
at  the  suggestion  of  Dr.  Eotch,  under  the  name  of  the  Walker- 
Gordon  Laboratory.  In  these  the  cows'  milk  is  standardised, 
and  milk  is  prepared  for  each  individual  infant  with  the  exact 
proportions  prescribed  by  the  physician,  and  sent  out  sterilised. 
The  following  is  an  example  of  such  a  prescription : — 

Proteids.         ......     1 '5  per  cent. 

Fat 3 

Sugar     .......     6  „ 

Number  of  feedings         ....     8 

Amount  for  each  feeding         .         .         .4  ounces. 
Heat  to  170°  F.,  30  minutes. 


The  following  table  shows  the  average  amount  recommended  to 
be  given  to  a  healthy  infant : — 


Percentages. 

Weeks  of  Life. 

Amount 
fed  in  ozs. 

Daily  Quantity 
in  ozs. 

Proteids. 

Fat. 

Sugar. 

First    .... 

0-75 

2-00 

4-50 

H 

4—15 

Second 

1-00 

2-50 

5-50 

If 

15—20 

Third  . 

1-00 

3-00 

6-00 

2 

20—24 

Fourth 

TOO 

3-00 

6-00 

9i 

24—30 

Eighth 

1-25 

3-50 

6-50 

H 

26—34 

Twelfth 

1-2.5 

3-50 

6 -.50 

at 

30—36 

Sixteenth     . 

l-oO 

3-75 

6-50 

H 

34—38 

Twenty-fourth 

1-75 

3-75 

6-50 

H 

36     40 

Thirty-second 

1-75 

4-00 

7-00 

6 

38—42 

Fortieth 

2-00 

4-00 

6-50 

61 

38—41 

Forty-eighth 

2-50 

4-00 

6-50 

^i 

40—45 

This  modified  milk  may  now  be  obtained  from  nearly  all  the 
large  dairy  companies  in  London  or  in  other  large  cities.  It  has 
the  disadvantage  of  being  somewhat  expensive.  When  the  mother's 
milk  causes  colic  it  will  often  be  advantageous  to  wean  the  infant 
and  use  the  modified  milk. 

Indications,  according  to  which  the  proteids,  fat,  and  sugar  are 
to  be  varied,  may  be  obtained  from  the  condition  of  the  infant. 
Excess  of  proteids  is  shown  by  undigested  curds  in  the  motions. 
This  condition  is  also  a  frequent  cause  of  colic.  Sometimes  there 
is  diarrhcea,  but  more  frequently  constipation.  Excess  of  fat  is 
indicated  by  frequent  vomiting.  It  is  sometimes  shown  by  frequent 
motions,  which  are  nearly  normal  in  appearance.     In  some  cases 


Management  of  the   Puerperal   State.      415 

they  contain  small  round  lumps  of  fat,  somewhat  resembling 
casein.  The  most  constant  indication  that  too  little  fat  is  given 
is  constipation  with  hard,  dry  motions.  If  too  little  sugar  is  given 
the  gain  of  weight  is  apt  to  be  too  slow.  Excess  of  sugar  may  be 
shown  by  colic,  or  thin,  green,  acid  motions.  If  the  gain  in  weight 
is  unsatisfactory,  and  there  is  no  sign  of  indigestion,  all  the 
ingredients  should  be  increased. 

In  many  cases,  especially  if  the  baby  is  at  all  delicate  or  prema- 
ture, the  best  i)lan  is  to  feed  it  on  peptonised  milk,  prepared  with 
Fairchild's  peptonising  powders  or  peptogenic  milk  powders.  By 
this  means  all  difficulties  are  avoided.  The  peptonised  milk  can  be 
given  either  pure  or  diluted  with  an  equal  quantity  of  water,  and 
when  the  child  is  ten  days  old  or  a  little  older  and  gaining  weight  plain 
boiled  or  sterilised  milk  can  be  substituted  by  slow  degrees  for  the 
peptonised,  a  teaspoonful  at  a  time.  By  this  means  even  the  most 
delicate  babies  can  be  reared  successfully  on  cows'  milk.  In  all 
cases  where  any  other  food  than  boiled  fresh  milk  is  being  used, 
such  as  peptonised  or  sterilised  milk,  or  one  of  the  patent  milk 
foods,  a  little  raw  meat  juice  or  orange  juice  should  be  given  to 
the  baby  daily  after  the  first  two  or  three  weeks  of  life. 

The  only  farinaceous  food  allowable  for  young  infants  are  those 
manufactured  on  the  principle  of  Liebig's  food,  in  which  the  starch 
is,  to  a  considerable  extent,  already  converted  into  glucose  by  the 
action  of  malt.  If  the  infant  will  not  thrive  on  milk,  and  a  wet- 
nurse  is  not  available,  such  a  food  may  be  tried.  Even  this, 
however,  does  not  answer  so  well  before  the  third  month  as  it  does 
after  that  time,  when  the  salivary  glands  are  beginning  to  be  active. 
Infant  foods  are  prepared  on  this  principle  by  Allen  &  Hanbury, 
Loflund,  Mellin,  Benger,  Horlick,  and  others. 

In  bottle-feeding  the  most  scrupulous  cleanliness  is  of  essential 
importance.  The  food,  unless  sterilised  as  described  above,  should 
be  prepared  fresh  each  time  of  feeding  ;  bottle  and  nipple  should 
be  most  carefully  cleansed  and  kept  in  water  when  not  in  use ;  and 
that  form  of  feeding-bottle  should  be  chosen  in  which  the  tube  is 
dispensed  with  entirely,  and  the  nipple  fitted  immediately  to  the 
neck  of  the  bottle.  If  the  milk  cannot  be  obtained  frequently 
fresh,  to  each  bottle  of  milk  may  be  added  a  grain  or  two  of 
bicarbonate  of  soda,  to  correct  any  acid  reaction  ;  or,  if  the  infant 
has  any  tendency  to  diarrhoea,  a  little  lime-water.  The  addition  of 
citrate  of  soda  in  the  proportion  of  one  or  two  grains  to  each  ounce  of 
milk  given  is  a  valuable  help,  since  it  has  the  property  of  retarding 
the  coagulation  of  the  proteid  and  increasing  its  digestibility. 
Regularity  of  meals  must  be  observed  as  with  breast-feeding.     The 


4i6  The  Practice  of   Midwifery. 

infant  should  always  be  nursed  while  it  is  feeding.  The  nurse  must 
never  be  allowed  to  let  the  bottle  remain  in  the  cradle  with  the 
infant  to  soothe  it  to  sleep. 

When  the  child  is  seven  months  old,  one  of  the  farinaceous  foods 
which  contain  all  the  ingredients  of  wheat,  not  merely  starch, 
should  be  given  in  addition  to  the  milk.  From  this  time  it  is  well 
to  give  also  some  gravy,  or  beef-tea,  with  a  little  bread. 


Chapter  XIX. 
ABNORMAL    PREGNANCY. 

Ectopic  or  Extra-uterine  Fcetation. 

Under  the  head  of  abnormal  pregnancy  may  be  included  all 
cases  of  what  is  commonly  spoken  of  as  extra-uterine  fcetation,  but 
may  receive  the  more  widely  inclusive  term  of  "  ectopic  "  fcetation. 
By  this  is  meant  the  arrest  of  the  ovum  at  some  jDoint  before  it  has 
reached  the  cavity  of  the  uterus.  Closely  allied  with  this  is  the 
development  of  the  ovum  in  one  horn  of  a  double  uterus,  when 
that  horn  is  so  rudimentary  that  pregnancy  cannot  go  on  in  a 
normal  course. 

Varieties. — The  ovum  may  either  escape  altogether  into  the 
peritoneal  cavity,  and  become  implanted  there,  or  it  may  become 
arrested  anywhere  in  its  course  between  the  Graafian  follicle  and 
the  uterine  cavity,  and  may  or  may  not  afterwards  escape  by  rupture 
from  its  original  situation.  Hence  we  have  the  following  varieties 
of  ectopic  fcetation  :  (1)  ovarian  ;  (2)  primary  abdominal ;  (3)  tubo- 
ovarian,  or  tubo-abdominal,  when  the  ovum  is  contained  in  a  sac 
formed  between  the  pavilion  of  the  tube  and  the  ovary,  or  a  portion 
of  the  peritoneum ;  (4)  tubal ;  (5)  tubo-uterine  or  interstitial,  when 
the  ovum  is  arrested  in  that  part  of  the  tube  which  passes  through 
the  uterine  wall ;  (6)  secondary  abdominal,  when  the  ovum  partially 
escapes  by  rupture  of  the  sac  ;  (7)  intra-ligamentous  or  extra- 
peritoneal, when  the  sac  formed  by  the  tube  ruptures  into  the 
broad  ligament,  and  the  ovum  develops  between  the  layers  of  the 
broad  ligament.  To  these  varieties  of  extra-uterine  fcetation  must 
be  added  :  (8)  pregnancy  in  an  abnormal  uterus,  generally  the 
rudimentary  horn  of  a  uterus  unicornis. 

Causation. — In  some  instances  obstacles  are  discovered  which 
may  have  impeded  the  course  of  the  ovum,  such  as  a  small  polypus  ^ 
at  the  mouth  of  the  Fallopian  tube,  or  a  fibroid  tumour.  It  is 
probable  that  in  some  cases  the  obstacle  may  consist  in  a  twisting 
of  the  tube  due  to  peritoneal  adhesions,  or  to  a  constriction  or 

1  Vassner,  Monats.  f.  Gyoiik.,  Bd.  17,  p.  881. 
M.  27 


4i8  The  Practice  of   Midwifery. 

atresia  of  the  tube,  which  the  semen  can  pass,  but  not  the  ovum. 
Such  conditions,  however,  cannot  usually  be  verified  by  autopsy  as 
having  existed  prior  to  impregnation,  on  account  of  the  great 
alterations  produced  by  the  inflammation  set  up  by  the  presence  of 
the  extra-uterine  sac,  and  indeed  are  not  usually  present. 

One  morbid  condition  has  been  found  in  the  remaining  parts  of 
both  tubes  in  cases  of  tubal  foetation,  namely,  a  chronic  catarrhal 
salpingitis,  with  some  loss  of  epithelium.  This  might  promote 
tubal  foetation  in  two  ways.  If  the  epithelium  were  entirely  lost  at 
some  spot,  the  ovum  might  adhere  more  readily,  as  it  is  supposed 
to  do  to  the  endometrium  after  the  superficial  exfoliation  of 
menstruation,  or  the  loss  of  epithelium  may  lead  to  the  failure  of 
the  current  set  up  by  the  action  of  the  ciliae  by  which  the  ovum 
normally  is  carried  into  the  uterine  cavity.  Salpingitis  further 
may  cause  irregular  adhesion  of  the  plicae  of  the  tube,  and  in  this 
way  culs-de-sac  may  be  formed  in  which  the  ovum  may  be  caught. 
These  diverticula,  which  by  some  writers  are  considered  of  congenital 
origin,  are  no  doubt  usually  the  result  of  salpingitis,  although,  in 
view  of  the  fact  that  the  ovum  embeds  itself  in  the  wall  of  the  tube 
as  it  does  in  the  uterus,  it  is  probable  that  in  many  cases  where  the 
ovum  has  been  supposed  to  be  lying  in  a  diverticulum  it  has  in 
reality  only  been  embedded  in  the  tubal  wall. 

Another  theory  of  causation  has  been  jDropounded  by  Webster, 
namely,  that  the  fault  lies  in  a  congenital  abnormality  of  the 
mucous  membrane  of  the  tube,  which  renders  it  susceptible  to  be 
stimulated  by  the  presence  of  an  ovum  to  produce  decidual  tissue, 
a  peculiarity  which  ought  to  be  limited  to  the  mucous  membrane  of 
the  uterus. 

Freund  and  Taylor  ^  are  inclined  to  regard  congenital  want  of 
development  of  the  tubes,  together  with  an  infantile  condition  of 
the  uterus  and  sterility,  as  a  possible  cause. 

In  a  very  large  number  of  cases  of  extra-uterine  gestation  nothing 
abnormal  can  be  detected  in  the  tubes,  and  Bland  Sutton  ^  main- 
tains that  this  variety  of  j)regnancy  occurs  as  often,  if  not  more 
often,  in  a  healthy  as  in  a  diseased  or  imperfectly  developed 
tube. 

Clinical  observation,  however,  tends  to  confirm  the  view  that  the 
cause  is  often  some  acquired  morbid  condition  hindering  normal 
pregnancy,  and  probably  also  altering  the  character  of  the  tubal 
mucous  membrane.  For  the  subjects  of  ectopic  foetation  are 
rarely  very  young,  generally  over  thirty  years  old ;  and,  in  many 

1  Taylor,  Extra-uterine  Pregnane^-,  London,  1899,  p.  24. 

2  Bland  Sutton,  Surgical  Diseases  of  the  Ovaries,  London,  1896,  p.  245. 


Abnormal   Pregnancy. 


419 


cases,  they  have  either  lived  for  years  in  sterile  marriage,  or  a 
good  many  years  have  elapsed  since  the  last  pregnancy.  If  the  cause 
of  extra-uterine  pregnancy  were  always  a  congenital  abnormality  it 
might  be  expected  that  it  would  generally  occur  in  a  first  pregnancy. 
Extra-uterine  pregnancy  soon  after  marriage  is  not,  however,  so 
rare  as  has  sometimes  been  supposed,  and  I  have  met  with  a  case 
in  which,  after  operation  for  ruptured  tubal  fcetation,  a  second 
normal  child  was  born  within  a  year  from  marriage. 

It  has  been  suggested  that  intense  mental  emotion  or  shock  may 
set  up  contractions  of  the  tubes  by  which  an  early  ovum  may  be 
arrested  in  its  passage  down  the  tube  and  may  continue  to  develop 
there.  Various  conditions  of  the  ovum  itself  have  also  been  cited 
as  possible  causes,  the  shedding  of  the  zona  pellucida  before  it 


Fig.  250. — Tubal  foetation,  with  the  corpus  hiteum  in  the  ovary  of  the  opposite 
side.     The  decidua  is  partly  detached  from  the  uterine  cavity. 

reaches  the  uterine  cavity,  its  over-development  either  causing  an 
actual  physical  difficulty  in  its  passage  through  the  tube  or  leading 
to  its  becoming  prematurely  embedded  before  it  has  reached  the 
uterine  mucosa. 

There  is  another  curious  mode  of  origin  which  appears  to  occur 
in  women  who  have  not  shown  any  degree  of  sterility;  namely,  the 
interference  of  one  ovum- with  another  on  their  way  to  the  uterus. 
According  to  Dr.  Parry's^  statistics — twin  pregnancies  are  at  least 
four  times  as  common  in  extra-uterine  as  in  normal  fcetation :  a 
proportion  which  proves  that  some  causal  relation  must  exist.  It 
has  been  thought  that  the  second  ovum  may  be  obstructed  by  the 
first  in  reaching  or  passing  along  the  tube.  These  statistics  have, 
however,  been  questioned  on  the  ground  that  cases  are  included  as 
twin  pregnancies  in  which  the  intra-uterine  has  followed  on  an  old 


1  i'arry,  Extra-uterine  Pregnancy. 


27—2 


420  The   Practice  of   Midwifery. 

extra-uterine  pregnancy,  with  the  foetus  still  retained  in  the 
abdomen. 

Tubal  pregnancy  may  occur  in  either  tube,  in  a  nullipara  or  a 
multipara,  in  the  first  or  any  subsequent  pregnancy,  and  may  be 
repeated  in  the  same  patient.  Multiple  pregnancies  in  the  tubes 
have  been  described  as  well  as  simultaneous  intra-uterine  and  extra- 
uterine pregnancy  and  the  development  of  both  blood  and  hyda- 
tidiform  moles.  Chorion  epithelioma  has  also  been  described, 
and  even  the  occurrence  of  eclampsia,  in  cases  of  advanced  tubal 
fcetation. 

Some  cases  of  tubal  fcetation  give  evidence  of  transperitoneal 
migration  of  the  ovum,  or  of  the  spermatozoa,  from  one  side  to 
the  other.  By  the  former,  those  cases  are  explained  in  which 
the  corpus  luteum  is  found  on  one  side  and  the  ovum  in  the 
opposite  Fallopian  tube  (see  Fig.  250) ;  by  the  latter,  those  in 
which  ovum  and  corpus  luteum  are  on  the  same  side,  but  the 
portion  of  tube  between  ovum  and  uterus  rudimentary,  or  evidently 
long  impervious.  The  wandering  of  the  spermatozoa  across  the 
peritoneal  cavity  by  their  own  movements  is  not  surprising.  Nor 
is  that  of  an  ovum,  if  it  be  remembered  that  probably  many  ova 
fail  to  reach  the  Fallopian  tube,  and  that  some  of  these  may 
happen  to  come  within  reach  of  the  current  of  serum  produced  by 
ciliary  action  toward  the  orifice  of  the  opposite  tube.  In  very 
rare  cases,  it  has  been  thought  to  be  proved  that  the  ovum  reached 
the  uterus  and  ascended  the  tube  of  the  opposite  side. 

Pathological  Anatomy — The  pathological  anatomy  and  usual 
course  vary  in  difi'erent  varieties. 

Ovarian  Foetation. — Until  quite  recently  some  authorities  denied 
the  possibility  of  ovarian  fcetation.  Several  recent  cases,  however, 
have  demonstrated  an  early  embryo  in  a  sac  within  the  ovary,  and 
the  evidence  is  now  admitted  as  convincing.  Ovarian  foetation  is 
very  much  rarer  than  tubal ;  but  now  that  its  possibility  is  estab- 
lished, it  is  probable  that  some  cases  in  which  the  pregnancy  was 
too  advanced  for  absolute  demonstration  were  really  ovarian.  It 
is  not  improbable  that  the  condition  known  as  blood-cyst  of  the 
ovary  may  sometimes  be  due  to  foetation,  as  in  the  case  described 
by  Kelly  and  Mcllroy.  It  is  probable,  however,  that  some  cases 
which  were  regarded  as  ovarian,  from  the  position  of  the  sac 
being  similar  to  that  of  an  ovarian  tumour,  without  any  peritoneal 
adhesions,  were  really  intra-ligamentous,  with  the  ovary  spread  out 
on  the  wall  of  the  sac.  Cases  of  advanced  pregnancy  are  not 
decisive,  since  the  tube  is   not  found  intact  at  that  stage.     The 


Abnormal   Pregnancy. 


421 


following  case,  reported  by  Van  Tussenbroeck/  appears  to  satisfy 
the  most  stringent  criteria  of  proof.  The  patient,  aged  31,  mother 
of  five  children,  having  had  no  menstruation  for  six  weeks,  had 
suddenly  signs  of  internal  haemorrhage,  and  the  diagnosis  of 
ruptured  extra-uterine  foetation  was  made.  Abdominal  section  being 
performed,  a  large  quantity  of  clot  and  blood  was  found  in  the 
peritoneal  cavity.  The  left  annexa  were  normal;  the  right  tube 
was  normal  and  free  from  adhesions,  the  right  ovary  was  capped 


Villi 


Lutein 
cell  layer 


Hilum   w'i'i\  u'.i 
of  ovary  \\U\"-''- 


Ovarian   tissue 
Fig.  251. — Ovarian  pregnancy.     (From  Eden.     Von  Tassenbroeck's  case).i 


by  a  small  tumour  the  size  of  a  walnut,  covered  with  coagulated 
blood.  The  tumour  was  not  adherent  to  the  tube  or  other  organs. 
This  tumour  was  found  to  be  a  foetal  sac,  containing  a  small  embryo, 
with  a  relatively  thick  funis  attached  to  the  wall  of  the  sac ;  at  its 
centre  was  an  opening  with  fringe-like  projections,  and  on  its  deep 
aspect  there  was  a  large  corpus  luteum.  The  fcetal  placenta  had 
a  structure  identical  with  the  normal;  there  were  two  layers  of 
epithelium  over  the  villi,  and  the  syncytium  was  typical. 


>  Annales  de  Gyn.  et  d'Obstet.,  IKiti).  Vol.  LTI.,  p.  'y'M. 


422  The  Practice  of   Midwifery. 

A  number  of  otlier  cases  have  now  been  recorded  in  which  a 
detailed  and  careful  examination  has  proved  the  existence  of  an 
ovarian  pregnancy  ;  among  these  are  the  cases  of  Thompson, 
Mendes  de  Leon,  Franz,  Kelly  and  Mcllroy,  Mikolitsch,  Freund 
and  Thome,  Munro  Kerr  and  Teacher.^  An  early  case  of  ovarian 
gestation  has  also  been  reported  by  Anning  and  Littlewood,  the  ovum 
being  about  fourteen  days  old,  and  a  doubtful  case  in  which  the 
ovum  had  nearly  reached  the  fourth  month  of  development  by  Croft. 

From  a  study  of  these  cases,  it  appears  probable  that  in 
ovarian  foetation  the  Graafian  follicle  ruptures  without  escape  of 
the  ovum  so  as  to  allow  the  spermatozoon  access  to  the  ovum  and 
its  fertilisation  in  situ.  The  development  of  the  ovum  may  then 
take  place  within  the  follicle,  the  opening  becoming  closed,  or  it  may 


Fig.  252. — Early  tubal  s^estation  unruptured,  situated  in  isthmus  of   tube. 
(Univ.  Coll.''Hosp.  Med.  School  Mus.,  Spec.  4218E.) 

burrow  its  way  out,  as  in  Van  Tussenbroeck's  case,  into  the  vascular 
tissue  lying  external  to  the  lutein  tissue  and  there  develop,  as  in 
the  case  described  by  INIunro  Kerr  and  Teacher.  The  vascularity 
of  this  tissue  markedly  favours  the  development  of  the  ovum. 
There  is  no  formation  of  any  structure  resembling  decidua.  The 
nutrition  of  the  ovum  is  carried  on  by  the  epithelium  of  the 
chorionic  villi,  which  are  bathed  in  maternal  blood,  lying  in  spaces 
in  the  ovarian  stroma.  As  the  ovum  continues  to  grow  gradual 
absorption  of  the  ovarian  stroma  takes  place,  and  the  sac  finally 
ruptures.  If  the  ovum  continues  to  grow  after  the  rupture  of  the 
sac  the  latter  is  composed  of  the  fcetal  membranes  only  with  the 
ovary  or  some  portion  of  it  attached  to  the  wall  of  the  sac.  In 
the  majority  of  cases  ovarian  j)regnancy  leads  to  rupture  and 
haemorrhage  before  the  third  or  fourth  month,  generally  within 
the  first  eight  weeks,  and  it  is  doubtful  if  it  can  ever  go  on  to  full 
term,  like  an  abdominal  pregnancy. 

The  ovum,  like  that  of  tubal  foetation,  is  often  converted  into  a 

1  Early  Development  and  Embryology  of  the  Human  Ovum,  Bryce  and  Teacher, 
Glasgow,  1908,  p.  67. 


Abnormal   Pregnancy.  423 

blood  mole,  as  in  Mikolitsch's  case ;    and  rupture  may  take  place 
after  this  conversion  as  well  as  before. 

Tubal  Foetation. — Tubal  foetation  is  the  commonest  of  all  the 
varieties  of  extra-uterine  gestation.  The  ovum  may  become  im- 
planted either  in  the  ampullary  or  isthmal  portion  of  the  tube, 
most  commonly  in  the  former.  It  may  be  attached  to  one  of  the 
folds  of  the  mucous  membrane  or  at  the  bottom  of  one  of  the 
intervening  depressions,  thus  constituting  the  columnar  and  inter- 
columnar  varieties  of  Werth.  Wherever  it  is  situated,  the  young 
ovum  quickly  embeds  itself  in  the  wall  of  the  tube,  burrowing 


Blood  clot. 


;'?<^„_     .-: ,  Lumen  of  tube. 

/ 


"^'-/■^ 


w 


Trophoblast.     Villus. 

Fig   253. — Tuball foetation  showing  intra-mural  site  of  ovum  outside  lumen  of  tube. 
(Filth,  Archiv  fiir  Gyn.,  Bd.  63,  Taf.  3,  Fig.  3.) 

into  the  muscular  layer,  so  that  it  acquires  really  an  intra- 
muscular site.  This  is  effected  by  the  activity  of  the  cells  of  the 
trophoblast  in  the  same  way  as  in  the  uterus,  and  is  associated 
with  swelling,  fibrinous  degeneration,  and  final  breaking  down  of 
the  muscle  cells  which  lie  in  contact  with  the  fcetal  elements.  In 
this  manner  an  implantation  cavity  is  formed  within  which  the 
ovum  lies. 

Decidual  cells  are  formed  in  some  measure,  especially  in  the 
neighbouring  plicse  of  the  tube,  and  round  the  borders  of  the 
ovum  ;  but  there  is  no  compact  layer  of  decidua  like  that  in  the 
uterus  to  afi'ord  attachment  to  the  villi  and  limit  their  penetration. 

The  amount  of  decidual  formation,  varies  very  largely  in  difi'erent 


424  The   Practice   of   Midwifery. 

cases,  and  appears  at  times  to  be  entirely  wanting.  It  has,  however, 
been  described  by  Whitridge  WilUams  and  others  in  the  non-pregnant 
tube  of  the  opposite  side.  If  situated  in  the  ampullary  portion  of 
the  tube,  the  developing  ovum  may  bulge  into  the  lumen  covered 
by  a  capsule  which  not  uncommonly  contains  some  muscle  fibres, 
and  which  rei^resents  the  decidua  capsularis,  the  so-called  capsular 
membrane.  With  the  continued  growth  of  the  ovum  the  lumen  of 
the  tube  may  become  entirely  obliterated,  and  the  sac  of  the  ovum 
may  become  fused  with  its  opposite  wall.  In  cases  of  isthmal 
pregnancy,  where  the  lumen  of  the  tube  is  smaller,  this  bulging 
does  not  as  a  rule  occur,  the  ovum  continuing  its  development  in 
the  tissues  of  the  wall,  the  lumen  being  obliterated  and  pushed 


Fig.  254. — A  tubal  mole  in  section,  sliowing  amniotic  cavity. 

aside.  In  most  cases  the  continued  growth  of  the  ovum  quickly 
leads  to  destruction  and  disappearance  of  the  decidua  capsularis. 

The  vascularity  of  the  tube  becomes  very  markedly  increased, 
and  at  first  there  is  some  slight  hypertrophy  of  the  muscle  cells. 
These  ultimately  are  replaced  by  connective  tissue  cells  to  a  con- 
siderable extent.  The  peritoneum  becomes  somewhat  thickened, 
and  adhesions  are  often  present  round  the  tubes  as  the  result  of 
the  peritonitis  which  is  set  up. 

The  development  of  the  intervillous  circulation  is  brought  about 
in  the  same  manner  as  in  the  case  of  an  intra-uterine  pregnancy, 
the  maternal  vessels  being  opened  up  and  their  walls  invaded  by 
the  cells  of  Langhans'  layer.  In  some  instances  the  invading  cells 
seem  to  undergo  proliferation  inside  the  lumen  of  the  vessels, 
and  this  may  be  the  explanation  of  some  of  the  cases  of  so-called 
deportation  of  the  chorionic  villi. 

In  consequence  of  its  intra-mural  site,  it  is  clear  that  the  developing 


Abnormal   Pregnancy.  425 

ovum  in  the  course  of  time  may  burst  either  through  the  wall  of  the 
tube  into  the  peritoneal  cavity  or  rarely  between  the  layers  of 
the  broad  ligament,  or  may  burst  into  the  lumen  of  the  tube. 
The  destruction  or  erosion  of  the  wall  of  the  tube  or  of  the  sac 
of  the  ovum  is  brought  about  in  two  ways :  firstly,  by  the  action  of 
the  epithelium  of  the  villi,  which  erodes  the  muscular  wall  or 
renders  it  very  thin  ;  and  secondly,  by  the  occurrence  of  haemor- 
rhages into  the  chorio-decidual  sj^ace.  Such  hsemorrhages  are  very 
likely  to  occur  from  comparatively  slight  causes,  owing  to  the  very 
frail  union  which  exists  between  the  foetal  and  maternal  tissues  in 
these  cases. 


Fig.  255. — Specimen  of  tubal  abortion.  The  fimbriated  extremity  greatly 
distended  by  a  clot.  (From  Kelley,  Operative  Gynecology,  1906,  Vol.  [I., 
Fig.  647.) 

Tubal  Mole. — In  a  considerable  proportion  of  tubal  pregnancies 
the  ovum  dies  at  an  early  period  of  its  development.  In  some  cases 
it  is  absorbed,  and  all  trace  of  it  disappears ;  in  others  it  forms  a 
hsematosalpinx.  In  others  again  the  occurrence  of  hsemorrhages 
into  the  chorio-decidual  space  is  followed  by  the  formation  of  a 
blood  or  so-called  tubal  mole,  followed  or  preceded  by  the  death  of 
the  embryo.  The  development  of  such  a  tubal  mole  is  no  doubt  the 
usual  accompaniment  or  precursor  of  the  bursting  of  the  ovum  into 
the  lumen  of  the  tube,  the  so-called  internal  rupture.  In  the 
majority  of  cases  the  abdominal  end  of  the  tube  becomes  closed 
about  the  eighth  week  of  a  tubal  pregnancy. 

Tubal  Abortion.— When  the  abdominal  ostium  remains  patent 
the   mole   lying  in  the   cavity  of   the    tube   sets   up   contractions 


426 


The  Practice  of   Midwifery. 


of  the  tubal  muscle  by  which  it  maybe  partially  or  wholly  extruded 
into  the  peritoneal  cavity.  When  the  extrusion  is  complete  it  is 
usually  accompanied  by  a  considerable  quantity  of  blood. 

The  symptoms  produced  are  generally  those  of  diffuse  intra- 
peritoneal hsemorrhage,  which  may  be  as  severe  as  in  the  case  of 
rupture  of  the  tube,  but  is  usually  less  so,  the  haemorrhage  being 
limited  by  contraction  of  the  gravid  tube,  which  soon  resumes  an 
almost  entirely  normal  appearance,  to  the  naked  eye. 

If  the  mole  is  only  partially  extruded,  or  if,  in  cases  where  it  is  still 
present,  the  embryo  alone  is  expelled,  the  hsemorrhage  usually 
continues,  leading  to  the  production  of  a  hematocele  of  varying  size. 

According  to  Martin,  two-thirds  of  the  cases  of  tubal  fcetation  end 
in  tubal  abortion.  The  reason  appears  to  be  that,  owing  to  the 
deficient  formation  of  decidua,  the  trophoblast  quickly  opens  up 


Fig.  256. — Tubal  ftetation.     Decidua  in  uterus  partly  separated. 

larger  maternal  vessels  than  in  uterine  pregnancy.  The  pressure 
of  the  blood  then  separates  the  attachment  of  the  ovum,  and  it 
bursts  into  the  lumen  of  the  tube. 

In  a  certain  number  of  cases  the  placenta  appears  to  continue  for 
some  time  a  kind  of  vegetative  growth,  so  that  a  mass  of  considerable 
size,  made  up  of  villi  and  blood  clot,  may  be  found,  without  any 
embryo.  The  possibility  of  such  an  occurrence  is,  however,  denied 
by  Wiiit ridge  Williams  and  Berry  Hart. 

The  mass  of  clot  may  contain  only  a  few  traces  of  degenerate 
chorionic  villi.  In  other  cases  none  are  found,  and  it  is  difficult  to 
decide  between  tubal  fcetation  and  hematosalpinx.  But  if  a  rounded 
mass  of  clot  is  found  in  one  tube,  the  other  tube  being  undilated, 
there  is  a  probability  in  favour  of  tubal  fcetation. 


Rupture  of  the  Tube. — Eupture  of  the  tube  may  be  brought 
about  as  the  result  of  several  causes.      No  doubt  in  many  cases  the 


Abnormal   Pregnancy. 


427 


wall  of  the  tube  is  destroyed — eroded — by  the  action  of  the  tropho- 
blast  or  by  the  growing  villi,  and  finally  perforated.  In  other 
instances  the  final  factor  is  the  occurrence  of  hsemorrhage  into  the 
tube,  resulting  in  its  over-distension  when  the  abdominal  ostium  is 
closed,  and  again  the  contractions  of  the  tubal  muscle  may  play  a 
part  in  producing  both  tubal  abortion  and  rupture. 

The  rupture  of  a  tubal  pregnancy  may  follow  directly  any  form  of 
muscular  exertion,  it  is  not  uncommonly  caused  by  sexual  inter- 
course, and  it  may  even  be  directly  due  to  examination  of  the 
pelvis.  In  a  case  under  my  care  a  mass  on  the  right  side  of  the 
uterus  was  found  to  collapse  during  bimanual  examination  under  an 
anaesthetic.      Two   days   later   a   definite   lump   could   be   felt   in 


*>«')*  } 


^A 


^'i--K^M 


Fig.  257. — Early  ruptured  ampullary  pregnancy.  The  ovum  is  seen  almost 
surrounded  by  villi.  The  ovary  presents  a  corpus  lutem,  and  the 
fimbriated  end  of  the  tube  is  partly  closed. 


Douglas'  pouch,  and  on  removal  this  was  found  to  be  a  blood  mole 
two  and  a  half  inches  in  diameter.  There  was  no  free  blood 
in  the  peritoneal  cavity.^ 

The  rupture  takes  place  usually  at  from  two  to  eight  weeks' 
growth,  within  the  period  of  the  erosive  activity  of  the  tropho- 
blast ;  more  rarely  in  the  third  month  :  a  few  cases  are  on  record 
in  which  a  tubal  foetation  has  gone  on  till  the  later  months,  or 
even  till  full  term.  This  is  only  possible  when  the  muscular  wall 
of  the  tube  undergoes  great  hypertrophy,  as  it  sometimes  does 
also  in  cases  of  pyosalpinx  or  hydrosalpinx,  becoming  a  quarter  of 
an  inch  thick  or  more.  The  growing  sac  then  separates  the  layers 
of  the  );road  ligament,  and  comes  to  have  a  pedicle  somewhat  like 

'  fialabin,  Trans.  01)81,  Soc.  London,  1005,  Vol.  XLYU.,  p.  332. 


428  The  Practice  of   Midwifery, 

that  of  an  ovarian  tumour  formed  by  the  stretched-out  base  of  the 
broad  ligament.  Its  position  is  therefore  not  unlike  that  of  an 
intra-ligamentous  pregnancy,  except  that  it  does  not  generally 
descend  so  deeply  into  the  pelvis.  In  a  case  recorded  by  Heinricius  ^ 
the  left  Fallopian  tube  was  found  post  mortem  to  be  enormously 
distended,  and  to  contain  two  full-term  children,  one  completely 
disintegrated,  the  other  well  preserved.  The  history  pointed  to  the 
first  conception  having  occurred  six  years,  the  second  about  one 
year  before  death. 

When  situated  in  the  isthmus  of  the  tube  a  tubal  fcetation 
commonly  ruptures  very  early,  even  as  early  as  the  second  week ;  if 
the  ovum  is  in  the  ampulla  of  the  tube,  rupture  is  commonly  later, 
as  from  six  to  eight  weeks,  and  abortion  is  more  likely  to  occur. 

The  embryo  alone,  or  the  whole  ovum,  may  escape  from  the  sac,  or 
the  whole  may  remain  within  it.  In  rare  cases  false  membranes 
form  a  new  sac  around  the  escaped  embryo,  and  pregnancy  goes  on. 
The  usual  result  of  rupture  of  the  tube  is  diffuse  intra-peritoneal 
haemorrhage.  If  the  patient  does  not  die  from  the  effect  of 
haemorrhage  some  peritonitis  is  set  up  by  the  effused  blood. 
After  a  time  the  blood  clots,  and  the  clots  may  be  shut  in  by 
peritoneal  adhesions,  and  form  masses,  mainly  behind  the  uterus. 
Eventually  the  fluid  part  of  the  blood  becomes  absorbed,  and  in 
time  the  clots,  unless  septic  infection  reaches  them  from  adjacent 
bowel.  The  ordinary  form  of  retro-uterine  hfematocele,  in  which 
the  uterus  is  displaced  forward  and  upward,  is  not  usually  a  sequel 
of  diffuse  intra-peritoneal  haemorrhage,  but  results  from  more 
gradual  bleeding,  associated  with  tubal  mole  or  tubal  abortion. 

Hematocele  and  Hfematoma. — Modern  evidence  has  shown  that 
pelvic  hsematocele  is  due  in  the  great  majority  of  cases  to  extra- 
uterine foetation.  The  limitation  of  the  blood  effusion  to  the  pelvis 
implies  gradual  and  rather  j)rolonged  bleeding.  In  most  cases  the 
first  blood  effused  sets  up  some  plastic  peritonitis,  and  the  blood 
becomes  shut  in  by  adherent  intestines.  As  the  bleeding  goes  on  the 
limited  space  is  dilated,  and  the  uterus  is  pushed  forward  and 
generally  upward,  so  that  the  cervix  lies  behind  the  toj)  of  the 
symphysis  pubis,  and  the  fundus  may  be  felt  superficially  under  the 
abdominal  wall,  above  the  pubes.  The  top  of  the  mass  may  often  be 
felt  on  abdominal  examination  rising  behind  and  above  the  level 
of  the  fundus,  sometimes  as  high  as  the  umbilicus.  Hsematocele 
may  result  from  rupture  of  the  tube  by  a  very  small  aperture,  so 
that  the  bleeding  is  gradual.  But  it  is  most  frequently  due  to  bleeding 

1  Heinricius,  Arch,  f,  Gynak,,  B.  4,  H.  1. 


Abnormal   Pregnancy.  429 

from  a  tubal  mole,  escaping  through  the  open  end  of  the  tube.  The 
term  perituhal  hcematocele  is  given  to  a  special  form,  in  which  the 
bleeding  is  still  more  gradual  than  in  the  usual  one.  The  slowly 
exuding  blood  becomes  enclosed  in  a  thin  cap  of  lymph  attached  to 
the  edges  of  the  tubal  orifice,  and  this  is  gradually  distended  as  the 
blood  effusion  increases,  while  its  thickness  is  increased  by  additional 
deposit  of  lymph.  Thus  a  blood-containing  pseudo-cyst  is  formed, 
enclosing  the  end  of  the  tube,  which  is  not  necessarily,  although 
generally,  adherent  to  any  other  structures.  If  the  effusion  takes 
place  through  a  minute  rupture  at  the  side  of  the  tube,  the  term 
paratuhal  hcematocele  is  employed. 

If  the  rupture  and  haemorrhage  takes  place  into  the  cellular 
tissue  of  the  broad  ligament,  and  not  into  the  peritoneal  cavity, 
the  result  is  a  pelvic  licematoma.  The  mass  thus  formed  is  rarely 
so  large  as  a  hsematocele,  being  in  an  enclosed  space  from  the 
first,  but  it  may  rupture  secondarily  into  the  peritoneal  cavity. 
A  hsematoma  generally  lies  to  one  side  of  and  somewhat  behind 
the  uterus,  and  pushes  the  uterus  over  toward  the  opposite  side 
of  the  pelvis.  In  some  cases,  however,  it  strips  up  the  peritoneum 
from  the  pouch  of  Douglas  and  from  the  back  of  the  uterus, 
extending  even  over  to  the  opposite  broad  ligament.  In  such 
cases  it  may  attain  to  a  large  size,  and  be  difficult  or  impossible 
to  distinguish  from  a  large  hsematocele.  The  ordinary  course 
both  of  hsematoma  and  hsematocele  is  to  be  very  slowly  absorbed. 
Sometimes,  however,  especially  when  of  very  large  size,  they  may 
suppurate,  being  generally  infected  by  organisms  from  the  bowel. 

In  iuho-ovarian  foetation,  the  ovum  is  arrested  at  the  pavilion  of 
the  tube,  which  is  already  adherent,  or  which  becomes  adherent,  to 
the  ovary,  and  thus  forms  the  foetal  sac.  The  course  appears  to 
resemble  that  of  abdominal  fcetation. 

In  tubo-ahdominal  foetation,  the  ovum  is  attached  to  the  pavilion 
of  the  tube,  and  the  sac  is  completed  by  adhesion  of  the  pavilion, 
after  implantation  of  the  ovum,  to  some  portion  of  the  peritoneum. 

In  tubo-uterine,  or  interstitial,  fwtation  (Fig.  258),  where  the  ovum 
is  arrested  in  the  uterine  portion  of  the  tube,  the  sac  as  it  enlarges 
most  frequently  projects  outwardly  at  the  angle  of  the  uterus, 
becomes  thinned  at  that  point,  and  rujDtures  before  the  fourth 
month.  No  undoubtedly  authentic  case  of  interstitial  pregnancy 
has  been  recorded  which  has  progressed  beyond  the  sixth  month. 

In  a  case  described  by  Eooswinkel  a  living  child  was  extracted 
from  the  abdomen  at  full  term,  but  in  this  instance  the  interstitial 
pregnancy  had  burst  into  the  abdominal  cavity  at  the  fourth  month, 
forming  a  secondary  abdominal  foetation. 


430 


The   Practice  of   Midwifery. 


If  the  sac  is  near  the  uterine  cavity,  it  may  bulge  into  that  cavity, 
and  then  a  part  of  the  ovam  may  escape,  or  be  extracted,  through 
the  natural  passage.-^  The  sac  in  this  form  of  fcetation  lies  outside 
the  lumen  of  the  tube,  as  in  ordinary  tubal  fcetation.  Eupture  com- 
monly occurs  later  than  in  tubal  fcetation,  in  the  third  or  fourth 
month. 

In  some  cases  of  interstitial  fcetation,  the  ovum  has  been  thought 
to  have  been  developed  in  an  abnormal  tube  running  in  the  wall  of 


Fig.  258. — Tubo-uterine,  or  interstitial,  fcetation.     (From  a  specimen  in  the 
museum  of  Guy's  Hospital.) 

the  uterus,  and  communicating  with  the  Fallopian  tube.^  Such  a 
tube  might  be  the  Wolffian  duct  or  a  portion  of  the  Miillerian  duct 
not  blended  with  the  duct  of  the  other  side,  and  may  open  into  the 
uterus  anywhere  between  the  uj)per  angle  and  the  external  os.  The 
uterus  would  be  really  a  more  or  less  complete  uterus  unicornis, 
although  externally  it  might  appear  normal. 

Intra-ligamentous  Fcetation. — This  is  a  rare  variety  of  tubal  gesta- 
tion, only  one  case  having  occurred  in  197  examples  of  extra- 
uterine   gestation   recorded  by  Martin  and  Werth.     The  primary 

1  Braxton  Hicks,  Trans.  Obst.  Soc.  London,  1867.  Vol.  IX.,  p.  57. 

2  Leopold,  Archiv  f.  Gynak.,  1878,  Bd.  13,  Hft.  3,  p.  355. 


Abnormal   Pregnancy. 


431 


implantation  of  the  ovnm  is  in  the  tube,  and  as  the  early  placenta 
grows  it  perforates  the  wall  of  the  tube  and  acquires  an  attach- 
ment to  the  cellular  tissue  of  the  mesosalpinx.  Owing  to  the 
extreme  vascularity  of  this  tissue,  no  doubt  in  the  great  majority 
of  cases  the  pregnancy  comes  to  an  end  as  the  result  of 
hfemorrhage  into  the  intervillous  spaces,  with  or  without  the 
formation  of  a  hgematoma.  If  the  ovum  continues  to  develoj) 
it  does  so  in  a  sac  in  the  cellular  tissue  between  the  layers  of 
the  broad  ligament.     The  wall  of  the  sac  may  be  thick,  with  a 


Fig.  259. — Sagittal  lateral  section  of  pelvis,  with  intra-llgamentous  foetation  in 
right  broad  ligament.  A,  amnion  ;  A.C.,  amnial  cavity  ;  fI,  placenta  ;  B.L.,  broad 
ligament;  P,  peritoneum;  F,  fcetus  ;  CA,  chorion  ;  R,  rectum;  L.A.,  levator 
ani ;  P.T.,  paraproctal  tissue  ;  O.I.,  obturator  internus.     (After  Berry  Hart.) 

considerable  layer  of  involuntary  muscular  fibre  over  its  surface, 
or  it  may  be  thin.  The  attachment  of  the  placenta  becomes 
extended  from  its  primary  site  in  the  tube  to  the  cellular  tissue 
lining  the  sac.  It  may  occupy  any  part  of  the  sac,  sometimes  its 
upper  portion,  near  the  original  position,  of  the  Falloj^ian  tube 
(Fig.  259),  sometimes  its  lower  portion,  beneath  the  fcetus,  where 
it  becomes  attached  deeply  to  the  cellular  tissue  at  the  base  of  the 
broad  ligament.  As  the  ovum  grows,  it  may  peel  the  peritoneum 
either  posteriorly  off  the  back  of  the  uterus  and  the  other  broad 
ligament  (posterior  intra-ligamentary  foetation),  or  it  may  extend 
anteriorly  and  peel  the  peritoneum  first  off  the  psoas  and  iliacus 


432 


The  Practice  of   Midwifery. 


muscle,  commencing  at  the  interior  face  of  the  broad  ligament,  and 
finally  of!  the  anterior  abdominal  wall  from  below  upward  (anterior 
intra-ligamentary  foetation).  In  other  cases,  but  more  rarely,  the 
broad  ligament  is  drawn  out  and  a  kind  of  pedicle  formed  from  it, 
like  that  of  an  ovarian  tumour.  Much  more  frequently  the  sac 
burrows  deeply  into  the  broad  ligament,  and  is  widely  attached  to 
the  cellular  tissue  of  the  pelvis,  as  shown  in  Fig.  259,  so  that  it  is 
difficult  or  impossible,  if  an  operation  is  performed,  to  make  a 
pedicle,  and  remove  the  whole  sac. 

As    a    synonym    to   intra-ligamentous    foetation,  the  terms  sub- 
peritoneo-pelvic  and  subperitoneo-aldominal  foetation  are  sometimes 


Fig.  260.- 


-Uterus  and  foetus  from  a  case  of  (.-'  secondary)  abdominal  foetation. 
The  placenta  is  connected  with  right  broad  ligament. 


used,  the  former  when  the  pelvic  peritoneum  only  is  stripped  up, 
the  latter  when  the  peritoneum  is  stripped  up  above  the  level  of  the 
pelvic  brim. 

As  Werth  contends,  it  is  possible  that  a  number  of  the  supposed 
cases  of  intra-ligamentary  gestation  are  in  reality  pseudo-ligamentary, 
being  examples  of  tubal  gestation  developing  behind  and  beneath 
the  broad  ligament.  In  such  cases  the  ovary  is  found  spread  out 
on  the  anterior  surface  of  the  tumour. 

In  a  true  intra-ligamentary  gestation  the  fcetus  may  go  on 
developing  up  to  full  term,  or  may  die  from  imperfect  nutrition, 
without  any  further  rupture,  at  any  time  during  the  course  of 
pregnancy,  generally  within  the  last  two  months.  In  some  cases, 
the  peritoneum  remains  free  from  inflammation  throughout;  in 
others,  peritonitis  is  set  up,  and  the  peritoneal  surface  of  the  sac 
becomes  adherent  to  pelvis,  intestines,  or  abdominal  wall. 


Abnormal   Pregnancy.  433 

In  other  cases,  again,  secondary  mpture  into  the  peritoneal  cavity 
occurs,  generally  in  the  third  or  fourth  month.  If  the  ovum  dies, 
the  patient  may  die  from  haemorrhage,  if  not  saved  by  abdominal 
section,  or  may  survive  with  the  formation  of  a  hsematocele. 
If  it  continues  to  live,  secondary  abdominal  fcetation  is  the  result. 

The  survival  of  the  foetus  must  depend  to  a  large  extent  on  the 
position  of  the  placenta.  If  this  is  situated  at  the  upper  part  of  the 
sac  above  the  foetus,  it  can  hardly  escape  some  damage  when  the 
sac  ruptures  ;  on  the  other  hand,  when  it  is  situated  at  the  bottom 
of  the  sac  below  the  foetus  rupture  may  occur  without  any  disturbance 
of  its  attachments,  and  in  such  a  case,  provided  that  the  membranes 
are  intact,  the  foetus  may  continue  to  develop  as  a  secondary 
abdominal  foetation. 

Secondary  Abdominal  Fc3etation. — This  variety  of  extra-uterine 
pregnancy  may  be  the  sequel  of  a  tubal  or  of  an  intra-ligamentary 
foetation.  In  the  first  case  it  is  possible  occasionally  for  the 
developing  ovum  to  escape  through  the  abdominal  end  of  the  tube 
into  the  peritoneal  cavity  and  to  continue  its  development,  as,  for 
example,  in  a  few  cases  of  tubo-ovarian  or  tubo-abdominal  preg- 
nancy. In  some  cases  the  ovum  may  even  survive  rupture  of  the 
tube  and  continue  to  grow.  In  such  instances  no  doubt  the  tube 
gives  way  by  a  process  of  slow  erosion  rather  than  of  rupture, 
and  the  foetus  enclosed  in  its  membranes  gradually  escapes  through 
the  opening  thus  formed  into  the  peritoneal  cavity.  When  a 
secondary  abdominal  foetation  is  the  result  of  the  rupture  of  an 
intra-ligamentary  foetation  the  ovum,  as  already  mentioned,  is  most 
likely  to  survive  if  the  placenta  is  situated  below  it  and  has  already 
acquired  a  firm  attachment  to  the  cellular  tissue.  The  broad 
ligament  then  continues  to  form  the  placental  site  just  as  the  tube 
does  in  the  first  variety.^ 

Generally  more  or  less  chronic  peritonitis  continues  during  the 
course  of  pregnancy,  and  the  foetus  becomes  enclosed  in  an  adven- 
titious sac  of  lymph.  Sometimes  there  is  no  peritonitis,  and  the 
foetus  is  found  enclosed  merely  in  its  membranes,  amnion  and 
chorion,  or  amnion  only.  Or,  again,  the  membranes  may  rupture, 
and  the  foetus  be  quite  free  among  the  intestines,  the  liquor  amnii 
being  absorbed  by  the  peritoneum.  The  placenta  often  forms  an 
elastic  mass,  toward  one  side,  separate  from  the  foetus,  and  simu- 
lating an  ovarian  tumour.     Pregnancy  may  go  on  to  full  term,  or 

1  Leopold's  researches  on  animals  have  shown  that  young  foetuses  when  introduced 
into  the  peritoneal  cavity  are  rapidly  destroyed  when  the  peritoneum  is  healthy  by  the 
action  of  phagocytes.      Archiv  f.  Gynak.,  1880,  Bd.  18,  Hft.  1,  S.  53. 

M.  28 


434 


The   Practice  of   Midwifery. 


the  foetus  may  die  from  imperfect  nutrition  or  from  pressure  at  any 
time  during  the  course  of  j)regnancy.  The  presence  of  muscular 
fibres  makes  it  more  Hkely  than  in  most  other  forms  that  the 
placenta  should  become  detached  by  contractions  of  the  sac  when 
false  labour  occurs. 

Primary  Ahdominal  Foetaiion. — The  possibility  of  this  is  still 
doubted,  but  there  is  no  d  priori  reason  against  it,  now  that  the 
possibility   of   ovarian   foetation    is    universally   admitted,  and   its 


Left  Fallopian 
tube. 


Eight  Fallopian 
tube. 


Left  ovary. 

Adhesion  of 

capsularis  to 

back  of  uterus. 


Capsularis. 


Right  ovary. 


Deepest  por- 
tion of  placen- 
tal site. 


Placental  site. 


Eectum. 
Fig.  2(il. — The  author's  case  of  primary  abdominal  foetation. 

occurrence  has  shown  that  "  the  ovum  is  capable  of  embedding 
itself  in  any  patch  of  connective  tissue  which  is  sufficiently  large  to 
accommodate  it,  and  sufficiently  vascular  to  meet  the  demands  of  its 
nutrition  "  (Teacher^).  It  is,  however,  almost  impossible  to  prove 
in  any  given  case,  because  there  is  a  possibility  that  the  ovum  may 
have  been  aborted  from  the  tube  at  a  very  early  stage,  and  after- 
wards have  implanted  itself  upon  the  peritoneum.  Cases  of  this 
kind  have  been  recorded  in  lower  animals,  in  which  the  original 


1  The  Early  Development  and  Embryology  of  the  Human  Ovum,  1908  (see  p.  49). 


Abnormal   Pregnancy.  435 

site  within  the  tube  was  discovered  on  microscopic  section.  A 
similar  case  in  woman  is  recorded  by  Tuholski.^  If,  however,  the 
ovum  damaged  by  separation  can  attach  itself  to  the  peritoneum, 
it  seems  still  more  likely  that  a  fresh  ovum  can  do  so.  Presumably 
the  peritoneal  epithelium  normally  prevents  attachment  of  the  ovum, 
and  such  attachment  can  only  occur  if  the  peritoneum  is  previously 
damaged. 

Most  of  the  cases  of  so-called  primary  abdominal  gestation  are 
no  doubt  instances  of  the  continued  growth  of  an  ovum  after  its 
extrusion  from  the  tube  or  from  between  the  layers  of  the  broad 
ligament. 

The  following  case  appears  open  to  no  other  interj)retation  than 
primary  abdominal  foetation.  Eupture  of  an  extra-uterine  foetation 
took  place  at  seven  weeks'  gestation,  and  the  patient  died  after 
operation  from  unexpected  syncope,  having  a  damaged  heart, 
although  hsemorrhage  had  not  been  very  extreme.  The  embryo  was 
found,  and  measured  f  inch  in  length.  Both  tubes  were  free  and 
pervious,  the  fimbrise  normal,  and  showed  no  sign  of  any  recent 
dilatation.  The  fcetal  sac  appeared  to  be  subperitoneal,  lying  at 
the  bottom  of  the  pouch  of  Douglas.  Its  attachment  was  two  inches 
away  from  the  nearest  ovary.  The  wall  covering  in  the  sac  was 
somewhat  adherent  to  the  back  of  the  uterus  and  broad  ligaments 
(see  Fig.  261),  but  was  free  above,  there  being  no  intestinal  adhesion. 
It  had  a  smooth  outer  surface  which  microscopically  resembled  in 
structure  the  peritoneal  surface  of  the  broad  ligament.  This  sac 
wall  (Fig.  261)  can  only  be  explained  as  being  a  decidua  reflexa  or 
capsularis,  derived  from  the  peritoneal  surface. 

This  specimen  was  examined  by  a  committee  of  the  Obstetrical 
Society  of  London,^  who  reported  that  it  was  probably  a  case  of 
primary  abdominal  foetation,  the  committee  considering  that  there 
was  a  possibility  that  the  ovum  might  have  been  at  first  implanted 
in  the  tube,  and  afterwards  transplanted  after  abortion  to  the  pouch 
of  Douglas.  But  now  that  it  has  become  known  that  the  decidua 
capsularis  is  formed  by  the  ovum  burrowing  at  once  into  the  maternal 
surface  before  the  formation  of  villi,  the  presence  of  a  decidua 
capsularis  seems  as  conclusive  proof  as  the  case  allows  that  the 
abdominal  implantation  was  primary. 

Witthauer  records  a  case  of  primary  abdominal  pregnancy.^ 
After  two  months'  amenorrhoea,  the  patient  had  symptoms  of 
internal  haemorrhage.     A  fd'tal  sac  of  the  size  of  a  hen's  egg  was 

'  Aiiier.  Gyii.  and  Obstet.  Journ.,  December,  1901. 

'^  Tnins.  Obst.  Soc.  London,  1896,  Vol.  XXXVIII.,  p.  88. 

»  Zentralbl.  f.  Gynak.,  Jan,  31,  1903,  No.  5,  p.  136. 

28—2 


43^  The  Practice  of   Midwifery. 

found  in  the  lower  end  of  the  omentum.  Chorionic  villi  were 
detected  in  it,  and  the  ovum  was  surrounded  by  blood  which 
separated  it  from  the  omental  tissue.  Both  tubes — not,  however, 
cut  in  serial  sections — and  ovaries  appeared  normal.  Nowhere  could 
any  union  be  discovered  between  the  cells  of  the  trophoblast  or  the 
epithelium  of  the  chorionic  villi  and  the  tissues  of  the  omentum, 
and  this  makes  it  probable  that  the  case  was  in  reality  one  of 
secondary  im23lantation,  like  most  of  the  others  described. 

Pregnancy  in  a  rudiinentari/  uterine  horn  (Fig.  262)  may  either 
lead  to  rupture  in  the  early  months — this  occurred  in  the  fourth  or 
fifth  month  in  twenty-four  out  of  forty-five  cases  of  rupture  collected 


Fig.  262. — Pregnancy  in  rudimentary  uterine  horn,  a,  junction  of  rudimentary 
horn  with  uterus  ;  *,  point  of  origin  of  round  and  ovarian  ligaments  and  Fallo- 
pian tube,  toward  outer  part  of  ectopic  sac  ;  c,  uterus  unicornis  dexter. 

by  Werth — or  the  foetus  may  go  on  developing  to  full  term,  as 
hapj)ened  in  26  per  cent,  of  his  cases. ^ 

In  the  latter  case,  the  pregnancy  may  be  marked  by  no  abnormal 
symptoms,  until  full  term  arrives,  or  some  peritonitis  may  occur  in 
the  course  of  pregnancy.  In  one  such  case,  that  of  a  primipara, 
I  removed  the  whole  tumour  unopened  after  full  term,  tied  the  base 
like  an  ovarian  tumour,  after  separating  extensive  adhesions,  and 
the  patient  recovered  as  quickly  as  from  an  ovariotomy.  Within  a 
year  she  had  had  a  second  child,  developed  in  the  remaining  half  of 
the  uterus,  and  normally  delivered. 

In  only  19  j)er  cent,  of  the  cases  did  the  band  of  tissue  uniting 
the  two  horns  contain  any  trace  of  lumen,  and  therefore  most  of  these 
cases  must  have  been  examples  of  external  migration  of  the  sper- 
matozoon. A  microscopic  examination  is,  however,  always  neces- 
sary to  prove  the  absence  of  any  canal,  and  this  has  often  not  been 

1  Werth  ;  Von  Winckel,  Handbuch  der  Geburtshiilfe,  Bd.  2,  T.  2,  p.  978. 


Abnormal   Pregnancy.  437 

carried  out.  The  mortality  when  rupture  does  occur  is  high : 
thirty-one  patients  out  of  forty-eight  died  almost  at  once  after  the 
occurrence  of  the  rupture.  Whether  the  pregnancy  continues  to 
full  term  or  rupture  occurs  depends  no  doubt  upon  the  degree  of 
development  of  the  muscular  tissue  of  the  rudimentary  horn. 

The  diagnosis  of  this  condition  is  usually  not  made  until  an 
operation  is  undertaken,  but  it  has  been  made  in  a  few  cases  even 
before  operation. 

Pregnancy  in  a  rudimentary  horn  is  distinguished  from  tubal 
pregnancy  by  the  fact  that,  in  the  former,  the  origin  of  the  round 
and  ovarian  ligaments  lies  to  the  outside  of  the  sac,  in  the  latter,  on 
the  inside  (Fig.  262). 

In  cases  of  multiple  pregnancy  and  tubal  gestation  three  possible 
conditions  may  be  present  :  the  two  foetuses  may  be  in  the  same 
tube,  there  may  be  one  foetus  in  each  tube,  or  there  may  be  a 
simultaneous  intra-uterine  and  extra-uterine  pregnancy.  When  both 
foetuses  are  in  the  same  tube  they  are  most  commonly  contained  in 
the  same  foetal  sac,  and  this  condition  has  been  seen  both  in  the 
early  and  the  later  months  of  pregnancy.  The  cases  in  which  there 
is  a  foetus  in  both  tubes  have  so  far  been  met  with  only  in  the 
early  months  of  pregnancy. 

Of  the  cases  in  which  one  foetus  has  been  in  the  uterus  and  one 
extra-uterine,  a  considerable  proportion  has  gone  on  to  full  term 
without  producing  grave  symptoms,  and  the  extra-uterine  tumour 
has  been  discovered  only  in  labour  or  after  delivery.  In  some  the 
extra-uterine  sac  has  ruptured,  or  haemorrhage  has  taken  place 
internally.-^ 

Neugebauer  ^  has  collected  171  cases  of  this  kind.  Of  these  no 
less  than  fifty-four  of  the  intra-uterine  foetuses  were  carried  to  full 
term,  and  forty- nine  were  born  alive,  while  of  the  extra-uterine 
foetuses  thirty-two  went  to  full  term,  but  only  four  were  born  alive. 
In  twenty-eight  cases  both  children  reached  full  term,  and  all  three 
in  one  case  of  triplets.  Of  the  patients  operated  upon  some  19  per 
cent,  died,  while  of  those  not  operated  upon  the  maternal  mortality 
was  nearly  50  per  cent. 

In  all  forms  of  ectopic  foetation,  the  uterus  becomes  considerably 
enlarged,  and  a  decidua  forms  in  it.  In  tubal  foetation,  the  uterine 
enlargement  is  greater  the  nearer  the  sac  is  to  the  uterus.  The 
increase  in  the  size  of  the  uterus  continues  usually  for  the  first  three 


1  As  in  a  case  reconlcd  by  the  authfd-,  'J'raiis.  Obst.  Soc.  London,  1881,  VoJ.  XXHI., 
p.  141. 

'''  Neugc))auer,  Zur  Leliro  der  Zwilliiigsschwangcrschaft  niit  heterotopem  Sitz  dei' 
Friichte,  Leipzig,  i;i07. 


438  The   Practice  of   Midwifery. 

months ;  and  during  the  fourth  month,  if  previous  interruption  of 
the  pregnancy  has  not  occurred,  the  uterus  commences  to  diminish 
in  size.  The  increase  in  size  is  due  to  hypertrophy  of  the  muscle 
tissue,  increased  vascularity,  and  the  formation  of  the  decidua. 
The  latter  at  the  height  of  its  develoj)ment  is  about  ^  to  1  cm.  in 
thickness.  Its  structure  is  that  of  the  decidua  of  pregnancy,  and  it 
presents  two  layers,  a  compact  and  a  spongy  layer.  The  degree  of 
development  and  the  date  of  its  formation  varies  in  different  cases, 
and  does  not  seem  to  follow  any  definite  law.  The  decidua  is 
detached  and  expelled  on  the  death  of  the  ovum  or  sometimes 
during  the  course  of  the  pregnancy,  either  as  a  whole  (see  Fig.  264) 
or  in  fragments.  In  the  early  months  progressive  enlargement  of 
the  uterine  cavity  is  an  important  evidence  of  continued  life  of  the 
foetus. 

When  pregnancy  goes  on  to  the  later  months,  the  child  is 
occasionally  well  formed,  but  more  often  it  is  smaller  and  less 
nourished  than  in  uterine  pregnancy,  and  deformities,  the  result  of 
pressure,  are  common,  occurring  in  at  least  50  percent,  of  all  cases.-"- 
They  aft'ect  in  the  order  of  frequency  the  head,  the  pelvis  and  lower 
extremities  and  the  upper  extremities  of  the  fcetiis.  If  the  foetus 
dies  before  full  term,  the  contents  of  the  sac  may  become  decomposed, 
or  suppuration  may  occur  in  it.  The  patient  may  then  suffer  from 
septic  absorption.  The  decomposition  in  the  sac,  notwithstanding 
the  exclusion  of  air,  is  probably  to  be  attributed  to  organisms 
making  their  way  in  from  the  blood  or  from  the  intestines,  which 
are  usually  in  close  vicinity.  More  rarely  the  sac  may  rupture  into 
the  peritoneal  cavity,  or  haemorrhage  may  occur  from  partial  detach- 
ment of  the  placenta,  the  blood  either  making  its  way  iuto  the  sac,  or, 
if  there  is  no  adventitious  sac,  reaching  the  general  peritoneal  cavity. 

When  full  term  is  reached,  if  the  child  is  alive  up  to  that  time, 
a  kind  of  sham  labour  often  takes  place  ;  uterine  contractions, 
accompanied  by  action  of  the  auxiliary  muscles  of  labour,  occur, 
and  separate  and  expel  the  uterine  decidua.  This  leads  to  a 
sanguineous  discharge  lasting  several  days.  The  child  dies  within 
a  few  days  from  the  onset  of  this  sham  labour.  In  other  cases 
the  decidua  is  expelled  before  the  full  term,  especially  if  the  child 
has  died  previously.  It  is  but  rarely  that  rupture  of  the  sac  is 
caused  by  the  sham  labour,  but  some  haemorrhage  may  take  place 
into  it.  In  most  cases,  after  death  of  the  child  decomposition  takes 
place  in  the  contents  of  the  sac,  causing  inflammation  and  suppura- 
tion, either  at  once  or  after  some  interval.     The  contents  may  then 

1  Von  Winckel,  Uber  die  Missbildungen  von  Ektopisch  Entwickelten  Fiiichten, 
Wiesbaden,  1902. 


Abnormal    Pregnancy. 


439 

escape  either  externally,  by  the  rectum,  the  vagina,  or  the  bladder. 
Ut  these  the  external  opening  is  most  favourable,  that  into  the 


rectum  the  commonest.  The  process  of  evacuation  may  be  pro- 
longed even  for  years,  if  not  assisted  artificially,  the  bones  coming 
away  piecemeal.     Eventually  the  patient  may  recover. 


440  The   Practice  of   Midwifery. 

In  other  cases  decomposition  does  not  take  place,  but  the  fluid 
in  the  sac  is  absorbed,  the  membranes  become  closely  applied  to 
the  body  of  the  foetus,  and  the  latter  becomes  mummified,  the  soft 
parts  being  converted  into  a  greasy  pulp,  or  gradually  changed  into 
adipocere.^  The  sac  and  fcetal  membranes  may  become  calcified 
from  deposit  of  lime,  the  so-called  lithokelyphos,  a  process  which 
aids  in  isolating  the  foetus  and  rendering  it  innocuous.  In  some 
cases  the  foetus  itself  becomes  more  or  less  calcified,  and  is  then 
called  a  "  lithopsedion."  Generally  only  the  integument  is  actually 
calcified,  the  deposit  of  lime  commencing  in  the  vernix  caseosa,  but  a 
similar  deposit  may  take  place  in  the  internal  organs  also.^  A 
mummified  or  calcified  foetus  may  be  retained  for  many  years  (in 
one  case  as  long  as  fifty-seven  years),  and  other  pregnancies  may 
occur  and  go  on  to  a  normal  issue.  In  one  instance  I  removed  the 
calcified  sac  with  a  lithopEedion  from  a  patient  in  whom  extra-uterine 
pregnancy  going  to  full  term  had  been  diagnosed  twenty  years 
before.  At  the  end  of  twenty  years,  abdominal  section  became 
necessary  on  account  of  the  development  of  an  ovarian  tumour  on 
the  other  side;  and  the  old  foetal  sac  w^as  removed  entire.  The  sac 
was  of  stony  hardness,  and  had  to  be  sawn  open  after  removal  with 
the  whole  of  the  broad  ligament.  The  foetus  was  calcified  externally  ; 
its  brain  was  intact  but  soft,  and  the  ventricles  of  the  brain  retained 
their  shape.  Inflammation  of  the  sac  is,  however,  liable  to  occur  at 
any  time. 

Symptoms. — In  cases  of  tubal  pregnancy,  when  ruj^ture  occurs 
early,  the  first  thing  which  may  indicate  that  there  is  anything 
amiss  is  that  the  patient,  who  often  considers  herself  in  good  health, 
has  a  sudden  attack  of  agonising  abdominal  pain  with  collapse  and 
signs  of  internal  haemorrhage.  There  may  or  may  not  have  been 
amenorrhoea  and  morning  vomiting  or  other  signs  of  early 
pregnancy.  The  intra-peritoneal  haemorrhage  is  often  accompanied 
by  severe  vomiting.  The  temperature  at  first  is  normal  or  sub- 
normal, but  after  a  day  or  two  becomes  elevated  from  peritoneal 
inflammation  or  from  the  absorption  of  fibrin  ferment  by  the 
peritoneum.  If  rupture  is  deferred  beyond  six  or  eight  weeks, 
general  symptoms  of  pregnancy  usually  exist,  and  attacks  of  acute 
spasmodic  pain,  partly  due  to  contractions  of  the  tube  and  partly  to 
intra-mural   haemorrhages,    tend    to    occur.      Generally   there   is 

1  Adipocere  is  a  soft  waxy  substance  composed  mainly  of  ammonium  margarate  with 
an  admixture  of  potassium  and  calcium  mai'garate. 

2  "  Note  on  tiie  so-called  Lithopsedion,"  by  Dr.  E.  Barnes,  Trans.  Obst.  Soc.  London, 
Vol.  XXIll.,  p.  170;  Kuchenmeister,  "  Uber  Lithopadion,"  Arch.  f.  Gynak.,  1881, 
Bd.  17,  Hft.  2,  s.  153. 


Abnormal   Pregnancy. 


441 


amenorrhoea,  but  irregular  discharges  of  blood  are  apt  to  take 
place,  especially  m  conjunction  with  the  attacks  of  spasmodic 
pain.  Even  the  continuance  of  regular  menstruation  is  not  a 
disproof  of  tubal  foetation.  In  many  cases,  the  commencement 
of  uterine  haemorrhage  indicates  death  of  the  ovum  and  the 
commencement  of  formation  of  a  tubal  mole.  If  no  intra-peri- 
toneal  hgemorrhage  or  tubal  abortion  occurs,  a  sanguineous  dis- 
charge generally  goes  on  for  weeks,  sometimes  for  two  or  three 
months.  The  uterine  haomorrhage  generally  implies  separation 
of  the  uterine  decidua  ;  and  this  may  be  expelled  at  once,  or  after 
some  interval.  Sometimes,  in  place  of  amenorrhoea,  there  is  a 
slight  continuous  sanguineous  dis- 
charge from  the  commencement  of 
pregnancy.  I  have  met  with  one 
case  in  which  the  commencement  of 
extra-uterine  foetation  during  lacta- 
tion was  marked  not  by  the  cessation, 
but  by  the  reappearance,  of  regular 
menstruation.  In  some  cases  rupture 
occurs  by  a  small  opening.  There 
may  then  be  milder  attacks  of  abdo- 
minal pain  with  symptoms  of  shock 
due  to  repeated  small  haemorrhages, 
followed  perhaps  by  a  more  marked 
attack  of  pain  due  to  a  severe  intra- 
peritoneal bleeding. 

It  must  be  remembered  that  in 
the  great  majority  of  cases  rupture 
of  the  tube  does  not  occur,  and  in 
such   the    classical    clinical    picture 

of  a  ruptured  tubal  gestation  is  not  seen.  Tubal  abortion  is 
marked  by  signs  of  internal  haemorrhage,  preceded  or  accom- 
panied by  spasmodic  pains  in  one  groin.  The  symptoms  are 
generally  not  so  extreme  as  in  rupture  of  a  tubal  foetation,  but 
may  be  so  severe  that  the  one  condition  cannot  be  distinguished 
from  the  other  till  the  abdomen  is  opened.  The  most  characteristic 
signs  of  an  early  tubal  pregnancy,  and  those  most  commonly 
present,  are — amenorrhoea,  one  period  at  least  having  been  missed  ; 
irregular  haemorrhage  from  t,he  uterus,  the  discharge  slight  in 
amount,  resembling  that  of  a  long-continued  period ;  repeated 
attacks  of  pelvic  pain,  often  associated  with  nausea  and  faintness ; 
and  the  occasional — in  al>out  25  to  BO  per  cent,  of  the  cases — 
passage  of  shreds  or  even  a  complete  uterine  decidua. 


Fig.  264. — Decidual  cast  from  case 
of  tubal  pregnancy. 


442  The   Practice  of   Midwifery. 

In  abdominal,  or  intra-ligamentous,  pregnancy  the  general  signs 
of  pregnancy,  including  amenorrhcea,  are  generally  present. 
Sometimes  nothing  abnormal  is  noted  till  full  term,  or  the  death 
of  the  foetus,  when  a  false  labour,  and  expulsion  of  decidua  from 
the  uterus,  followed  by  a  kind  of  lochial  discharge,  supervene. 
More  frequently  unusual  abdominal  pain  is  felt,  especially  on 
movement  of  the  foetus ;  and  in  abdominal  pregnancy  attacks  of 
peritonitis  usually  occur ;  or  the  whole  of  pregnancy  may  be  a 
course  of  subacute  peritonitis.  In  intra-ligamentous  pregnancy 
there  are  often  j)ressure  symptoms,  especially  if  the  sac  descends 
low  into  the  jDolvis.  If  the  sac  is  on  the  left  side,  more  or  less 
intestinal  obstruction  may  be  produced  by  the  sigmoid  flexure  being 
distended  over  it.  After  death  of  the  foetus  there  are  frequently 
the  constitutional  signs  of  inflammation  of  the  sac,  peritonitis,  and 
septic  absorption.  There  may  be  previously  irregular  bleeding  and 
exj)ulsion  of  a  uterine  decidua,  but  not  so  frequently  as  in  tubal 
foetation. 

Diagnosis. — A  tubal  foetation  may  be  suspected  if  there  are 
general  signs  of  early  pregnancy,  accompanied  by  attacks  of 
spasmodic  pain,  and  irregular  haemorrhage,  and  if  a  tumour  of 
corresponding  size  is  felt  at  one  side  of  or  behind  the  uterus. 
Probably  in  most  cases  of  tubal  foetation,  while  the  ovum  is  alive, 
there  is  no  symptom  beyond  amenorrhoea  ;  and  symptoms  only 
commence  when  abortion  or  rupture  occurs,  or  when  the  ovum  dies 
and  a  tubal  mole  begins  to  form.  Thus,  when  a  successful  operation 
has  been  performed  for  an  unruptured  tubal  foetation,  the  condition 
is  generally  that  of  a  tubal  mole. 

If  tubal  abortion  has  occurred,  and  a  pelvic  hgematocele  has 
formed,  a  soft,  boggy,  tender  mass  can  be  detected  in  the  pelvic 
cavity  usually  behind  and  to  one  side  of  the  uterus.  The  degree  of 
displacement  of  the  uterus  gives  a  clue  to  the  size  of  the  tumour, 
which  is  often  somewhat  indefinite  in  outline,  although  at  times  it 
can  be  felt  reaching  above  the  pelvic  brim  with  a  convex  upper 
border. 

In  cases  in  which  the  ovum  continues  to  live  after  the  first  eight 
weeks,  ballottement  may  possibly  be  discoverable  somewhat  earlier 
than  in  normal  pregnancy,  as  in  a  case  recorded  by  Thomas,  of  New 
York.  If  a  swelling  is  detected  at  the  side  of  the  uterus,  not  yet 
advanced  enough  to  give  signs  of  foetal  life,  and  if  a  manifest  souffle 
is  heard  over  the  swelling,  there  is  a  strong  presumption  in  favour 
of  extra-uterine  foetation.  The  cervix  uteri,  in  the  early  months, 
will  probably  resemble  that  of  ordinary  pregnancy,  and  the  uterus 


Abnormal   Pregnancy.  443 

will  be  enlarged,  but  not  so  globular  as  in  uterine  pregnancy.  Its 
position  varies,  but  generally  it  is  pushed  to  one  side  and  forward, 
the  sac  lying  rather  behind  it.  If  there  is  a  strong  presumption  in 
favour  of  extra-uterine  pregnancy,  sufficient  to  make  it  justifiable 
to  run  the  risk  of  inducing  abortion,  the  diagnosis  may  be  con- 
firmed by  passing  the  sound  into  the  uterus,  and  making  out  that 
it  is  empty.  A  sudden  severe  attack  of  faintness  and  collapse,  with 
signs  of  internal  haemorrhage,  commencing  with  sharp  pelvic  pains, 


V 


Fig.  265. — Degenerate  villi  in  blood  clot  in  wall  of  tube  from  case  of 
tubal  pregnancy . 

will  justify  a  probable  diagnosis  of  ruptured  tubal  foetation,  especially 
if  menstruation  has  been  arrested  for  a  few  weeks.  A  small  lump 
at  one  side  of  the  uterus  may  perhaps  be  discoverable  only  if  an 
anaesthetic  is  given  for  the  examination.  The  discharge  of  a  decidua 
from  the  uterus  without  any  ovum  or  chorionic  villi  is  a  very 
strong  confirmation  of  a  diagnosis  of  extra-uterine  foetation.  'J'his 
occurrence  affords  a  strong  presumption,  if  not  absolute  proof,  of  the 
death  of  the  ovum.  If  it  is  afterwards  found  that  the  length  of  the 
uterine  cavity,  measured  by  the  sound,  diminishes  instead  of 
increasing,    the   death    of  the   ovum  is  confirmed.     Again,  if  the 


444  The   Practice  of   Midwifery. 

cavity  of  the  uterus  is  found  to  be  little  or  not  at  all  increased, 
there  is  a  presumption  that  the  ovum  has  been  dead  for  some 
weeks,  and  that  the  uterus  has  become  involuted,  assuming  that 
the  diagnosis  of  extra-uterhie  foetation  is  established  on  other 
grounds. 

In  the  later  months,  when  the  foetation  will  generally  be  of  the 
abdominal  or  intra-ligamentous  variety,  the  presence  of  a  living 
foetus  would  be  ascertained  by  auscultation  and  palpation.  A 
souffle  like  the  uterine  souffle  may  be  heard,  but  not  so  constantly 
as  in  normal  pregnancy.  The  difficulty  will  now  be  to  distinguish 
between  extra-uterine  and  uterine  pregnancy.  The  apparently 
superficial  position  of  the  foetus  is  an  unreliable  sign,  for  this  may 
simply  result  from  thinness  of  the  uterine  wall.  In  the  later 
months  the  cervix  will  generally  be  less  softened  than  in  normal 
pregnancy,  but  in  some  cases  the  softening  is  so  considerable  that 
this  distinction  fails.  The  enlargement  of  the  uterus  does  not  con- 
tinue to  increase  beyond  three  or  four  months.  The  diagnosis  may 
be  made  absolute,  if  the  uterus  can  be  made  out  as  separate  from 
the  sac  containing  the  foetus.  On  the  other  hand,  if  marked  changes 
of  firmness  and  laxity  are  manifest  in  the  sac  containing  the  foetus, 
the  sac  is  almost  certainl}^  the  uterus.  As  before,  if  the  case  is  very 
critical,  diagnosis  may  be  comi^leted  by  use  of  the  sound.  Not 
infrequently  the  cervix  becomes  patent  enough  to  allow  the  finger 
to  jDass  and  ascertain  the  emptiness  of  the  uterus,  especially  about 
the  time  of  the  exjDulsion  of  the  decidua.  In  intra-ligamentous 
pregnancy,  the  placenta  may  sometimes  be  made  out  to  be  at  the 
top  of  the  sac,  and  some  part  of  the  foetus  may  be  felt  low  down  in 
the  pelvis,  with  no  placenta  intervening.  The  uterus  will  be  more 
or  less  pushed  over  to  one  side,  though  the  sac  may  extend  in 
front  of  or  behind  it.  Abdominal  foetation  may  sometimes  be  dis- 
tinguished from  intra-ligamentous  by  the  placenta  forming  an 
elastic  fluctuating  tumour  distinct  from  the  foetus,  and  by  more 
marked  signs  of  peritonitis  during  the  course  of  the  pregnancy. 
The  parts  of  the  foetus  may  also,  in  some  cases,  be  felt  more 
superficially,  and  pain  will  be  produced  when  they  are  handled. 

In  the  case  of  combined  extra-uterine  and  uterine  pregnancy, 
diagnosis  from  pregnancy  complicated  by  a  tumour  is  very  difficult, 
and  can  only  be  made  by  recognising  foetal  life  in  both  tumours. 

If  the  patient  is  only  seen  after  the  death  of  the  foetus,  the 
distinction  will  have  to  be  made  between  extra-uterine  foetation  and 
an  ovarian  or  uterine  tumour,  and  must  depend  chiefly  uj)on  a 
history  of  pregnancy,  not  ending  in  delivery,  and  the  recognition  of 
parts  of  the  foetus,  especially  the  head,  by  palpation,  abdominal  or 


Abnormal  Pregnancy.  445 

bimanual.  Since  histories  are  often  unreliable,  it  may  be 
impossible  to  make  an  absolute  diagnosis,  except  by  exploratory 
incision. 

If,  when  abdominal  section  is  performed  in  the  later  months,  a 
free  peritoneal  cavity  is  opened,  and  the  sac  is  found  to  be  also 
covered  by  peritoneum,  the  pregnancy  must  be  either  intra-liga- 
mentous  or  advanced  tubal.  The  latter  can  only  be  distinguished 
by  the  presence  of  a  more  definite  muscular  wall,  below,  as  well  as 
above,  and  continuous  with  the  wall  of  the  Fallopian  tube. 

Tubo-uterine  foetation  is  distinguished  from  tubal  by  the  absence 
of  any  portion  of  tube  between  the  sac  and  the  uterus,  and  by  the 
origin  of  the  round  ligament  being  outside  the  sac.  In  pregnancy 
in  a  rudimentary  horn,  the  origin  of  the  round  ligament  is  also  out- 
side the  sac,  but  the  sac  is  not  continuous  with  the  uterus. 

Prognosis. — Extra-uterine  foetation  is  almost  always  fatal  to  the 
child,  and  very  dangerous  to  the  mother.  The  mortality  of  cases 
in  which  tubal  foetation  was  positively  ascertained  was  formerly  a 
very  high  one  (97  per  cent.,  Puech).  Of  late,  however,  a  consider- 
able number  of  cases  has  been  saved  by  abdominal  section,  mostly 
after  rupture  of  the  sac  ;  and,  in  some  cases,  when  a  diagnosis  has 
been  made  in  the  first  few  weeks  of  pregnancy,  before  rupture.  In 
most  of  these,  however,  the  tube  appears  to  have  contained  a  tubal 
mole,  and  not  a  living  ovum. 

Among  114  cases  recorded  by  SideP  and  Werth^  operated  upon 
for  profuse  intra-peritoneal  haemorrhage  there  were  sixteen  deaths, 
or  14  per  cent.  Of  thirty-one  recorded  cases  of  interstitial  pregnancy 
treated  by  operation  four  died. 

It  is  now  recognised  that  a  large  proportion  of  cases  of  tubal 
foetation  end  in  recovery,  without  operation,  by  tubal  abortion  or  the 
formation  of  a  tubal  mole,  hsematocele,  or  hsematoma.  Champneys^ 
records  seventy-five  cases  treated  in  St.  Bartholomew's  Hospital, 
and  diagnosed  as  extra-uterine  foetation,  in  which  operations  were 
only  performed  on  account  of  some  urgent  indication.  The 
mortality  of  the  whole  was  9*3  per  cent.  Nine  primary  abdominal 
sections  were  performed  with  a  mortality  of  22*2  per  cent.,  and 
seventeen  secondary  abdominal  sections  with  a  mortality  of  29"4 
per  cent.  No  operations  during  the  life  of  the  foetus  were 
included. 

In  291  cases  of  tubal  abortion  with  the  formation  of  a  pelvic 

'  Sidel,  Inaug.  Diss.,  Berlin,  1903. 

2  Werth  ;  Von  Winckel,  Handbuch  der  Geburtshulfc,  Vol.  II.,  Bd.  2,  s.  93. 

"  Champneys,  Journ.  OVjstet.  and  Gyn.  Brit.  Emp.,  Vol.  I.,  1902,  p.  585. 


44^  The   Practice  of   Midwifery. 

hsematocele  treated  expectantly  by  Fehling/  Zweifel,^  and  Thorn,^ 
there  were  no  deaths. 

On  the  other  hand,  the  results  of  operative  treatment  are  almost 
equally  good.  Thus  out  of  284  cases  operated  upon  there  were  only 
six  deaths.  The  question  is  not,  however,  one  which  can  be  decided 
by  statistics  alone.  A  good  deal  will  depend  upon  the  class  of  the 
patient,  the  length  of  time  she  can  afford  for  getting  well,  and  the 
nature  of  the  hsematocele. 

In  intra-ligamentous  or  abdominal  foetation,  reaching  the  later 
months,  the  mortality  is  still  very  high.  According  to  Harris,*  the 
result  of  twenty-seven  cases  of  abdominal  section  for  advanced 
extra-uterine  pregnancy  with  a  living  child  up  to  1887  was  a  mor- 
tality of  93  per  cent. :  of  145  additional  cases  up  to  1897  a  mortality 
of  31  per  cent.,  thus  showing  the  improvement  due  to  the  advance 
of  surgery. 

Better  results  than  these,  however,  have  been  recorded.  Thus 
Sittner^  from  1887  to  1900  collected  forty-eight  cases  with  a 
living  fcetus  in  which  total  extirpation  of  the  sac  was  carried  out 
with  a  maternal  mortality  of  12'5  per  cent.,  and  thirty-five  cases 
where  the  placenta  was  left  in  situ  with  a  maternal  mortality  of 
42*8  per  cent.,  while  during  the  j^ears  1896  to  1900  alone  the 
mortality  in  the  former  class  was  only  5*5  per  cent,  and  in  the 
latter  33*3  per  cent. 

Treatment. — If  there  are  signs  of  diffuse  intra-^Deritoneal 
hfemorrhage  and  a  suspicion  of  extra-uterine  foetation,  the  treat- 
ment is  to  perform  abdominal  section  at  once,  and  remove  the  foetal 
sac  if  one  is  found.  Within  the  first  eight  weeks  of  pregnancy 
there  are  generally  no  adhesions,  and  the  operation  is  an  easy  one. 
If  the  patient  is  extremely  collapsed  from  hasmorrhage  and  the  pulse 
bad,  strychnine  should  be  given  subcutaneously  before  operation, 
and  rej)eated  in  case  of  need  during  the  operation.  An  ample 
supply  of  sterilised  normal  saline  solution  (chloride  of  sodium, 
gr.  Ix.  adOj.)  should  be  prepared  and  an  assistant  be  ready  to  inject 
it  into  a  vein  in  the  arm,  as  soon  as  the  bleeding  vessels  have  been 
secured,  in  the  manner  described  in  Chapter  XXXVIII.  It  is 
better,  if  possible,  to  secure  the  vessels  before  the  transfusion, 
otherwise  the  increase  of  vascular  pressure  increases  the  bleeding. 

1  Fehling,  Zeitschr,  f.  Geburt,  u.  G-yri.,  1898,  Bd.  38,  ss.  67—100. 

2  V.  Scanzoni,  Arch.  f.  Gyn.,  1902,  Bd.  6.5,  s.  562. 

3  Thorn,  Miinch.  Med.  Wochenschr.,  1903,  No.  21,  p.  893. 

^  Amer.  Journ.  of   Obstet.,  1887,  XX.   1154—1167  ;  Monatschr.  f.  Geb.  uud  Gynak., 
1897,  VI.  137—156. 
5  Sittner,  Zentralblatt  f.  Gynak.,  1903,  No.  2,  p.  33. 


Abnormal   Pregnancy.  447 

But,  if  the  patient  is  in  imminent  danger  of  dying  from  the 
hsemorrhage,  the  injection  may  be  commenced  immediately  before 
or  simultaneously  with  the  operation. 

Even  if  the  signs  are  those  of  only  moderate  internal  haemorrhage, 
it  is  better  to  perform  abdominal  section,  provided  that  the  patient 
is  seen  within  two  or  three  days  from  their  occurrence.  For  a  first 
moderate  bleeding  may  be  followed  by  a  more  copious  one.  And, 
if  the  blood  is  left  to  be  absorbed,  it  is  more  likely  that  peritoneal 
adhesions  will  be  set  up  and  future  sterility  result,  than  if  the  blood 
is  evacuated  and  the  gravid  tube  removed.  There  is  also  the  risk, 
if  the  haemorrhage  is  at  all  considerable,  that  the  clot  may  become 
septic,  from  its  vicinity  to  the  intestine,  and  thus  set  up  extensive 
inflammation,  and  require  secondary  operation. 

Oi^eration  for  Diffuse  Hemorrhage. — If  blood  is  found  in  the 
peritoneal  cavity,  the  first  step  should  be  to  find  which  tube  con- 
tains the  foetal  sac,  and  to  draw  it  up  into  the  incision.  A  pair  of 
pressure  forceps  is  then  placed  temporarily  on  the  infundibulo- 
pelvic  ligament,  securing  the  ovarian  artery,  and  another  close  to 
the  angle  of  the  uterus  to  secure  the  communicating  branch  of  the 
uterine  artery.  The  broad  ligament  is  secured  by  ligatures,  and 
the  tube  with  sac  removed,  the  ovary  being  left  if  possible.  The 
abdominal  cavity  is  then  cleared  of  blood,  and  may  be  washed  out 
with  sterilised  saline  solution  (gr.  Ix.  ad  Oj.),  while,  if  the  patient  is 
ansemic  from  loss  of  blood,  but  not  so  extremely  so  as  to  require 
intra-venous  transfusion,  it  is  well  to  leave  a  quart  of  this  solution 
in  the  peritoneal  cavity.  Its  absorption  is  promoted  if  the  foot  of 
the  bed  is  raised  upon  blocks  about  a  foot.  The  fluid  then  gravitates 
toward  the  i^art  of  the  peritoneum  near  the  diaphragm,  where 
absorption  is  more  active.  An  enema  of  saline  solution  after  the 
operation  is  also  useful. 

If  a  probable  diagnosis  of  early  tubal  foetation  is  made  before 
symptoms  of  haemorrhage  bave  occurred,  and  a  lump  is  felt  in  the 
position  of  the  Fallopian  tube,  it  is  advisable  to  make  an  exploratory 
abdominal  section  if  it  is  doubtful  whether  the  ovum  is  dead  or 
alive,  or  if  there  is  reason  to  think  that  it  is  only  just  dead.  For 
serious  haemorrhage  may  occur  even  after  the  death  of  the  ovum. 
If,  however,  it  is  probable,  on  account  of  long-continued  sangui- 
neous discharge,  or  from  evidence  that  the  uterus  has  become 
involuted,  that  tlie  ovum  has  been  dead  for  a  considerable  time,  it 
may  be  sufficient  to  keep  the  patient  completely  at  rest  for  many 
weeks,  in  the  hope  that  the  tubal  mole  may  shrink  and  become 
absorbed.  The  rest  should  be  prolonged  as  long  as  there  is  any 
sanguineous  discharge  and  for  at  least  a  week  or  two  longer.      The 


448  The   Practice  of   Midwifery. 

surgeon  should  be  prepared  to  perform  an  abdominal  section  at 
once,  in  case  of  symptoms  of  haemorrhage  appearing. 

If  there  have  been  symptoms  of  haemorrhage,  and  the  physical 
signs  of  pelvic  haematocele  or  haematoma  have  appeared,  it  may 
be  presumed  that  the  ovum  is  dead,  and  that  the  bleeding  is 
gradual  and  limited  by  adhesions  or  cellular  tissue.  The  question 
of  operation  must  then  be  decided  by  the  circumstances  of  each 
case.  As  a  general  rule,  if  there  is  a  presumption  that  the  embryo 
is  so  small  that  it  can  readily  become  dissolved,  that  is  to 
say,  if,  as  is  usually  the  case,  it  has  not  reached  two  months' 
development,  it  is  better  to  wait  so  long  as  matters  are  quiescent, 
keeping  the  patient  at  rest  in  bed.  The  blood  will  generally  even- 
tually become  absorbed.  If  the  swelling  begins  to  diminish,  the 
patient  is  likely  to  get  well  without  operation ;  if  further  increase 
occurs,  an  operation  will  generally  be  necessary. 

If  there  is  reason  to  believe  that  the  foetus  has  lived  beyond  two 
months,  an  operation  is  advisable,  for  the  probability  is  that  the 
foetus  will,  sooner  or  later,  break  down  and  become  septic.  It  is 
not,  however,  always  possible  to  determine  the  point  without  an 
exploratory  incision.  In  a  doubtful  case,  examination  of  the 
pelvis  with  the  X-rays  and  a  screen,  or  a  skiagraph  of  the  pelvis, 
may  demonstrate  the  presence  or  absence  of  a  fcetus  with  developed 
bones,  and  its  size.  As  regards  the  choice  of  operation,  if  there  is 
evidence  of  commencing  sepsis,  the  swelling  should  be  evacuated  at 
once  from  the  vagina.  The  same  mode  of  access  is  generally 
advisable  if  operation  is  decided  on  because  the  swellingundergoes 
increase,  or  fails  for  a  long  time  to  show  signs  of  diminution,  or  is 
very  excessive  in  size,  unless  there  are  symptoms  of  fresh  rupture 
or  haemorrhage  into  the  general  peritoneal  cavity.  In  case  of  doubt 
as  to  the  nature  of  the  tumour,  or  whether  such  fresh  rupture  has 
occurred,  it  is  often  useful  to  make  an  exploratory  abdominal 
incision  first.  If  the  pelvis  is  then  found  to  be  completely  covered 
in  by  adhesions,  or  if  the  swelling  proves  to  be  a  hgematoma  in  the 
broad  ligament,  the  blood  should  be  evacuated  through  the  vagina, 
and  the  abdominal  incision  closed.  In  the  case  of  hsematoma,  the 
abdominal  incision  is  useful  to  guide  the  direction  of  the  vaginal 
evacuation,  so  that  it  avoids  the  peritoneum.  In  a  case  of 
hsematoma  of  the  broad  ligament,  the  absorption  appears  often  to 
be  slower  than  that  of  an  intra-peritoneal  effusion,  and  the  course 
of  the  case  is  shortened  by  vaginal  evacuation. 

Operation  of  Vaginal  Evacuation. — The  patient  is  placed  in  the 
lithotomy  or  exaggerated  lithotomy  position,  and  the  legs  secured 
by  leg  rests  or  Clover's  crutch.     After  shaving  of  the  pubes  and 


Abnormal   Pregnancy.  449 

disinfection  of  the  vulva  and  vagina,  the  cervix  is  drawn  down- 
ward and  forward  by  vulsella.  An  incision  is  made  with  scissors 
through  the  posterior  vaginal  fornix  in  the  direction  of  the  most 
prominent  or  softest  part  of  the  swelling,  but  inside  the  course  of 
the  ureter.  Fine  pointed  forceps  are  pushed  into  the  swelling, 
and  the  opening  enlarged  by  separation  of  the  blades,  and  then 
by  the  fingers  until  two  fingers  can  be  introduced.  Clots  are  then 
scooped  out  by  the  fingers  and  the  cavity  washed  out  with  sterilised 
normal  saline  solution,  or  with  an  antiseptic  such  as  a  solution 
of  chinosol  1  in  400,  if  the  contents  are  septic.  Finally  the  cavity 
is  plugged  with  iodoform  gauze.  The  gauze  is  to  be  changed  at 
about  two  days'  interval,  and  the  opening  from  the  vagina  kept 
open  by  its  means  until  the  cavity  has  closed  up.  Thevenard  ^ 
has  recorded  fifty-three  cases  treated  by  posterior  colpotomy  with- 
out a  death. 

Treatment  after  the  Early  Months. — If  there  is  evidence  that  the 
ovum  is  growing,  or  that  the  fcetus  is  alive,  after  the  second,  and 
especially  after  the  third  month,  it  generally  means  that  the  fceta- 
tion  is  converted  into  a  ligamentous  or  secondary  abdominal 
pregnancy.  The  risk  either  of  operating  during  the  life  of  the 
foetus  or  of  waiting  is  then  very  much  greater  than  if  the  ovum 
is  dead.  Unless  the  whole  gestation  sac  can  be  removed,  the 
attempt  to  remove  the  placenta  is  likely  to  cause  fatal  haemorrhage, 
the  placental  site  being  unable  to  contract  and  close  the  vessels. 
If  the  placenta  is  left  untouched,  there  is  not  always  a  sufficiently 
firm  sac  which  can  be  isolated  from  the  general  peritoneal  cavity. 
The  placenta  has  to  decompose  and  come  away.  If  rapid  decom- 
position occurs,  there  is  a  current  of  maternal  blood  passing 
amongst  decomposing  villi,  and  almost  inevitable  saprsemia  or 
septicsemia  as  the  result  (see  Chapter  XXXIX.).  The  decomposition 
is  also  likely  to  lead  to  early  separation  of  placenta  and  haemor- 
rhage. Even  late  decomposition  of  the  placenta  produces  more  or 
less  septic  absorption,  and  haemorrhage  occasionally  takes  place 
on  separation,  even  as  late  as  several  weeks  after  the  removal  or 
death  of  the  foetus. 

In  deciding  on  treatment  no  regard  should  be  paid  to  the  life 
of  the  foetus,  for  the  foetus  is  generally  more  or  less  deformed  by 
pressure  or  lack  of  adequate  nutrition,  and  rarely  lives  for  more 
than  a  short  time,  even  if  delivered  alive  by  operation  at  full  term. 

In  general,  it  is  advisable  to  perform  abdominal  section  as  soon 
as  the  diagnosis  is  made,  because  the  less  advanced  is  the  preg- 
nancy, the  greater  is  the  probability  that  it  will  be  possible  to 

1  These  do  I'aris,  1890. 

M.  29 


450  The  Practice  of   Midwifery. 

remove  the  foetal  sac  entire,  or  at  any  rate  the  placental  site.  If 
this  can  be  done,  and  the  vessels  suj)plying  the  placenta  secured, 
the  risk  of  the  operation  may  be  reduced  to  a  small  one. 

The  decision  is  a  more  doubtful  one,  if  the  pregnancy  has 
reached,  or  is  close  upon,  full  term,  or  if  there  is  evidence  that 
the  foetus  is  on  the  point  of  perishing.  Some  have  then  considered 
it  advisable  to  wait  from  four  to  six  or  eight  weeks  after  the  death 
of  the  child,  provided  that  no  symptoms  of  sepsis  arise.  For  the 
risk  of  the  ojDeration  is  much  less  after  the  maternal  circulation 
through  the  placenta  has  ceased  :  provided  that  a  septic  condition 
has  not  supervened. 

Similarly,  if  the  foetus  is  already  dead,  and  matters  are  quiescent, 
it  may  be  advisable  to  wait  for  a  similar  jDeriod  after  its  death,  but, 
if  more  than  that  time  has  already  elapsed,  to  operate  at  once.  If 
any  symptoms  of  commencing  sepsis  or  decomposition  in  the  sac 
appear,  operation  should  be  undertaken  at  once,  before  the  patient's 
general  condition  becomes  too  unfavourable. 

Dunning^  collected  twenty-five  recorded  cases  in  which  the 
primary  operation  was  performed  during  the  viability  of  the  foetus, 
with  a  maternal  mortality  of  40  j)er  cent.,  and  thirty-three  cases  in 
which  the  secondary  operation  was  performed  after  the  death  of 
the  foetus,  with  a  maternal  mortality  of  42"3  per  cent.,  a  greater 
one  than  that  of  38'8  per  cent,  given  in  the  earlier  statistics  of 
Parry,  of  thirty-six  cases  treated  by  secondary  operation.  He 
concluded  that,  in  the  majority  of  cases,  the  operation  should  be 
undertaken  while  the  child  is  still  living.  Harris'  statistics  of  145 
cases  of  primary  operation  during  the  life  of  the  foetus,  including 
the  months  before  viability,  give  a  still  better  result  of  the  primary 
operation,  namely  a  mortality  of  31  per  cent.  The  figures  given  by 
Sittner,  already  quoted  (see  p.  446),  of  forty-eight  cases  operated 
upon  with  total  removal  of  the  sac  and  a  maternal  mortality  of 
only  12*6  per  cent.,  show  that  the  correct  principle  is  to  operate  as 
soon  as  the  diagnosis  is  made,  and  in  all  cases  if  possible  to  remove 
the  sac  and  placenta  entire.  But  it  must  be  remembered  that,  in 
reckoning  this  mortality,  cases  are  not  included  in  which  it  was 
found  impossible  to  remove  the  sac  with  the  placenta,  and  that  the 
total  mortality  of  Sittner's  eighty-three  cases  of  operation  with  a 
living  foetus  (1887—1900)  is  25*3  per  cent. 

Operation  in  the  Later  Months. — In  the  primary  operation,  the 
first  essential  is  to  avoid  wounding  the  placenta  until  the  vessels 
supplying  it  have  been  secured.  The  site  for  commencing  the 
incision  should  therefore  be  toward  the  upper  part  of  the  abdomen, 

1  Amer.  Journ.  of  Obstet.,  November,  1899,  Vol.  XL.,  p.  592. 


Abnormal   Pregnancy.  45 1 

or  where  some  foetal  part  is  felt  so  superficially  that  there  cannot 
be  placenta  over  it.  If  such  a  site  cannot  be  found  in  the  median 
line  of  the  abdomen,  the  incision  may  be  made  anywhere  else. 

The  most  favourable  chance  for  removing  the  whole  sac  is  when 
the  foetation  is  intra-ligamentous,  especially  if  the  placenta  is 
situated  at  the  top  of  the  sac.  If  the  child  is  not  viable,  it  is 
better  to  remove  the  sac  unopened,  if  possible.  Occasionally  the 
sac  may  have  formed  a  kind  of  pedicle  like  an  ovarian  tumour,  by 
drawing  out  the  broad  ligament,  which  can  be  tied  without 
difficulty.  More  frequently  it  descends  deeply  into  the  pelvis. 
Its  complete  removal  may  then  require  the  removal  of  the  uterus. 
The  ovarian  artery  on  the  affected  side  may  be  tied  first,  then  that 
on  the  opposite  side.  Next  the  peritoneum  is  divided  transversely 
in  front  of  the  uterus  and  stripped  down  with  the  bladder.  Then 
the  uterine  artery  on  the  unaffected  side  is  tied,  the  broad  ligament 
is  divided,  the  uterus  is  cut  across-  near  the  internal  os,  and  lastly 
the  uterine  artery  of  the  affected  side  is  tied  below  the  sac  and  the 
sac  removed.  The  peritoneal  edges  are  afterwards  united  by 
sutures,  and,  if  this  can  be  done,  the  abdomen  may  be  closed 
without  drainage.  The  steps  of  the  operation  are  similar  to  those 
in  hysterectomy  for  a  fibroid  tumour  extending  into  one  broad 
ligament.^  If  it  is  difficult  to  secure  the  uterine  artery  on  the 
affected  side,  or  if  the  bleeding  is  not  arrested,  it  may  be  advisable 
to  tie  the  anterior  branch  of  the  internal  iliac  artery,  or,  if  this 
cannot  be  separated,  its  main  trunk,  at  the  pelvic  brim. 

If  the  child  is  viable,  the  sac  must  be  incised  at  some  spot  where 
its  parts  are  felt  superficially  and  show  that  there  is  no  placenta. 
The  funis  is  tied  at  once  on  the  foetal  side  and  the  child  removed. 
The  placental  end  may  be  left  untied.  The  gestation  sac  is  then 
treated  in  the  way  already  described. 

If  the  sac,  with  the  placenta  at  the  bottom  of  it,  descends  so 
deeply  into  the  pelvic  cellular  tissue  that  it  is  judged  impossible 
to  remove  it  entire,  the  placenta  should  be  left  untouched,  the  sac 
stitched  to  the  abdominal  wound,  a  wide  orifice  being  left,  and 
plugged  with  iodoform  gauze.  The  plug  must  be  renewed  from 
time  to  time.  A  similar  treatment  may  be  adopted  if  the  first 
incision  opens  the  sac  without  opening  the  general  peritoneal 
cavity.  At  a  later  stage,  if  decomposition  has  begun,  or  haemor- 
rhage occurs  from  partial  separation,  it  may  be  advisable  to  detach 
the  placenta  completely  and  renew  the  plug  tightly. 

If  the  pregnancy  turns  out  to  be  abdominal,  it  may  happen  that 

^  For  a  description  and    figures  of  the  operation   see  the   author's   "  Diseases   of 
WomeT;." 

29—2 


452 


The  Practice  of   Midwifery. 


the  general  peritoneal  cavity  is  shut  off  by  a  firm  adventitious  sac 
of  false  membrane,  and  is  not  opened  by  the  incision.  In  that 
case  it  may  be  advisable  to  leave  the  placenta  untouched  and  plug 
the  sac  in  the  manner  already  described.  As  a  general  rule,  the 
adventitious  sac  will  be  imperfect,  or  not  strong  enough  to  isolate 
the  general  j)eritoneal  cavity  securely.  It  will  then  be  even  more 
important  than  in  the  case  of  intra-ligamentous  pregnancy  to 
remove  the  placental  site  entire.  This  will  generally  consist  of  a 
sac  in  the  broad  ligament  into  which  the  primary  rupture  of  the 
tubal   foetation   occurred.     It  can  usually  be  removed  unless  the 


Fig.  266. — Mikulicz  tampon. 


placenta  has  spread  on  to  surrounding  parts  which  cannot  be 
removed,  such  as  intestine  or  pelvic  wall.  If  the  placental  site 
cannot  be  removed  entire,  and  there  is  no  sac  which  can  be  stitched 
to  the  abdominal  incision,  the  only  plan  is  to  leave  the  placenta 
untouched  and  to  fill  the  pelvis  with  a  large  Mikulicz  tampon,  a 
gauze  bag  with  thread  attached  to  the  bottom,  filled  with  strips  of 
iodoform  or  sterilised  gauze  (Fig.  266),  by  which  the  intestines  are 
held  back  and  a  large  opening  into  the  pelvis  maintained.  The 
strips  of  gauze  filling  the  bag  are  renewed  at  intervals,  so  as  to  keep 
the  intestines  out  of  the  pelvis  until  the  placenta  has  broken  down 
and  come  away. 

Drainage   may  also  be  required  on   account  of   bleeding  from 


Abnormal  Pregnancy.  453 

adhesions  which  cannot  be  satisfactorily  arrested.  If  extensive 
pressure  is  required,  the  Mikulicz  tampon  should  be  used.  Other- 
wise the  best  plan  is  to  open  the  posterior  vaginal  fornix  from  the 
pouch  of  Douglas,  upon  the  blades  of  a  pair  of  forceps  pushed  up 
by  an  assistant  from  below.  A  strip  of  iodoform  gauze  is  passed 
from  above  into  the  vagina,  about  an  inch  being  left  within  the  peri- 
toneal cavity.  The  strip  is  removed  at  the  end  of  two  or  three 
days. 

In  the  secondary  operation  the  procedure  is  the  same  if  no  sepsis 
has  occurred,  and  it  is  equally  important  to  remove  the  whole  sac, 
or  placental  site,  entire  if  possible.  If  sepsis  or  decomposition  has 
taken  place  in  the  sac,  the  object  is  to  evacuate  the  sac  without 
contaminating  the  general  peritoneal  cavity.  If  a  month  or  more 
has  elapsed  since  the  death  of  the  foetus,  it  will  most  likely  be 
possible  at  once  to  peel  off  the  placenta  without  very  serious 
haemorrhage,  and  plug  the  sac  with  iodoform  gauze,  its  edges 
having  been  stitched  to  the  abdominal  wound,  if  the  general 
peritoneal  cavity  has  been  opened  at  all.  The  attempt  to  separate 
the  placenta  should  be  begun  cautiously  from  the  edge,  since  the 
date  after  the  death  of  the  foetus  at  which  the  maternal  circulation 
in  the  placenta  ceases  is  very  uncertain. 

If  the  placenta  is  left  untouched,  it  generally  begins  to  separate 
in  about  a  week.  Loose  pieces  may  be  removed  piecemeal,  but,  if 
bleeding  occurs  on  the  separation,  it  is  better  to  pull  off  the  whole 
and  arrest  the  bleeding  by  plugging  with  gauze,  aided  if  necessary 
by  external  pressure  by  an  abdominal  belt.  When  the  gauze  is 
changed,  the  sac  may  be  washed  out  with  an  antiseptic  solution, 
such  as  chinosol  1  in  400,  or  tinct.  iodi  5j.  ad  Oj. 

If  the  placenta  is  wounded  or  detached  at  the  operation,  or  has 
become  detached  before,  the  best  chance  of  arresting  bleeding  is  to 
place  quickly  one  or  more  thin  Doyen  clamp  forceps  to  compress 
the  base  of  the  sac.  The  ovarian  and  uterine  arteries,  or  if  neces- 
sary the  internal  iliac  artery  on  the  affected  side,  may  then  be 
sought  for  and  tied,  and  the  placenta  removed.  If  haemorrhage 
cannot  be  completely  arrested,  a  Mikulicz  tampon  may  be  used, 
filling  the  pelvis,  and  compressing  the  bleeding  site. 

In  a  case  of  doubtful  diagnosis,  when  the  patient  is  first  seen 
some  months  or  more  after  the  full  term  of  the  supposed  pregnancy, 
the  right  treatment,  as  a  rule,  is  to  clear  up  the  diagnosis  by 
exploratory  incision.  The  foetus  or  the  tumour,  as  the  case  maybe, 
can  then  generally  be  removed. 

When  the  sac  has  suppurated,  and  bones  begin  to  escape  either 
externally,  or  through  some  internal  cavity,  as  the  rectum,  vagina, 


454  The  Practice  of   Midwifery. 

or  bladder,  Nature  should  be  aided  in  the  evacuation.  So  far  as 
possible  the  opening  should  be  enlarged  by  stretching  rather  than 
cutting.  For  this  purpose,  tents  will  sometimes  be  found  useful. 
An  anaesthetic  being  given,  the  bones  may  then  be  extracted  by 
finger  or  forceps. 

In  some  cases,  an  extra-uterine  foetus,  at  or  near  full  term,  has 
been  successfully  removed  through  the  vagina.  This  operation 
should  only  be  undertaken  when  the  sac  bulges  toward  the  vagina, 
and  when  some  foetal  part  can  be  felt  at  the  accessible  portion  of  it. 
This  will  give  some  security  that  the  placenta  is  not  situated  there. 
In  the  absence  of  such  evidence,  it  is  very  likely  to  be  found  so 
placed.  Here,  again,  the  most  favourable  case  is  that  of  intra- 
ligamentous pregnancy,  when  the  j)lacenta  will  probably  be  at  the 
top  of  the  sac.  The  sac  may  be  opened  by  the  knife  of  the  benzoline 
or  galvano-cautery  to  diminish  the  risk  of  hemorrhage.  This 
method  will  not,  however,  avail  to  do  so,  if  the  placenta  is  the  part 
first  encountered.  The  placenta  should  be  left  untouched.  It  may 
be  necessary  to  extract  the  foetus  by  forceps  or  craniotomy.  The 
sac  should  be  plugged  with  iodoform  gauze  in  the  first  instance,  and 
afterwards  regularly  washed  out  with  antiseptics,  and  it  may  be 
useful  to  insert  a  large  drainage-tube  into  it.  In  some  cases  the 
vaginal  method  of  removal  may  be  chosen  when  a  previous 
abdominal  incision  appears  to  show  this  to  be  the  best  plan,  the 
placenta  lying  at  the  toj)  of  the  sac,  and  some  part  of  the  foetus 
presenting  low  in  the  pelvis. 


Chapter  XX. 

DISORDERS  OF  PREGNANCY  DUE  TO  REFLEX 
TOXIC  AND  MECHANICAL  CAUSES. 

The  disorders  of  pregnancy  may  be  divided  into  four  classes  : — 
(1.)  Those  arising  from  reflex  nervous  influence,  associated  with  the 
changes  in  the  nervous  centres  induced  by  pregnancy,  and  the 
increased  tissue  metabolism  which  it  causes,  with  the  possible 
accumulation  in  the  mother's  blood  of  various  excretory  products 
the  result  of  such  metabolism.  (2.)  Those  which  result  from 
mechanical  effects.  (3.)  Morbid  conditions  of  the  uterus  and  ovum. 
(4.)  Diseases  independent  of  pregnancy,  but  of  such  a  nature  that 
the  disease  is  influenced  by  the  pregnancy,  or  the  course  of  pregnancy 
by  the  disease.  In  some  cases,  such  as  puerperal  convulsions, 
the  disease  may  have  a  complex  causation,  depending  upon  more 
than  one  of  the  above  causes. 

Many  of  the  disturbances  which  come  under  the  first  class  are 
exaggerations  of  those  reflex  symptoms  of  pregnancy  which  may  be 
regarded  as  normal,  or  scarcely  morbid.  They  depend  not  only 
upon  the  presence  of  a  certain  source  of  irritation  in  the  pregnant 
uterus,  but  upon  the  increased  irritability  of  the  nervous  centres 
which  is  associated  with  pregnancy.  This  increased  irritability 
itself  may  be  regarded  as  physiological,  when  within  due  limits,  but 
in  persons  of  highly  excitable  neurotic  temperament  it  may  become 
excessive,  and  may  take  a  morbid  form,  such  as  hysterical  manifes- 
tations, neuralgia,  vomiting,  or  convulsions. 

In  other  cases  the  so-called  auto-intoxication  of  pregnancy  may 
play  a  part ;  that  is,  a  condition  supposed  to  be  induced  in  the 
mother  by  the  undue  accumulation  in  her  body  of  the  waste  products 
of  her  tissue  metabolism  and  that  of  the  foetus.  It  is  assumed  that 
in  certain  conditions,  as  the  result  of  some  failure  of  the  proper 
excretory  functions  of  the  liver  and  the  kidneys,  such  bodies  may  be 
retained  and  accumulate  in  the  mother's  blood.  Their  exact  nature 
is  not  quite  certain,  but  there  appears  to  be  some  evidence  in  favour 
of  the  view  that  they  are  the  products  of  proteid  disintegration. 

Nausea  and  Vomiting. — The  well-known  morning  sickness, 
which  is  generally  ^chiefly  observed  in  the  second,  third,  and  fourth 


456  The  Practice  of   Midwifery. 

months,  and  passes  off  in  the  later  months,  affecting  one-third  to 
one-half  of  all  pregnant  women,  has  been  already  described  among 
the  signs  of  pregnancy.  But  in  some  rare  cases  the  neurosis  takes 
a  much  more  severe  form.  The  vomiting  may  not  be  limited  to  the 
morning,  but  occur  at  all  times  in  the  day,  and  it  may  persist  in 
the  later  months  of  pregnancy.  In  extreme  cases  all  food  taken 
may  be  quickly  rejected.  There  may  be,  in  addition,  such  a 
continual  feeling  of  nausea  that  all  appetite  is  destroyed. 

Causation. — The  disorder  is  to  be  regarded  as  one  of  the  reflex 
neuroses  associated  with  the  increased  irritability  of  nervous  centres. 
The  special  source  of  irritation  appears  to  be  the  stretching  of  the 
fibres  of  the  uterus  in  consequence  of  its  growth.  Thus  vomiting 
is  more  marked  in  primiparse,  in  whom  the  resistance  to  expansion 
may  be  presumed  greater  ;  and  it  has  sometimes  been  found  to  be 
excessive  in  cases  where  there  has  been  an  unusually  rapid  expan- 
sion, such  as  those  of  twin  pregnancy,  hydrops  amnii,  or  vesicular 
mole.  Again,  vomiting  is  sometimes  found  to  cease  when  the 
foetus  dies,  although  it  is  retained  for  a  time  within  the  uterus. 
The  cause  cannot,  however,  be  passive  distension  by  the  ovum, 
since  the  ovum  does  not  completely  fill  the  uterus  in  the  months 
during  which  vomiting  is  most  marked.  Women  who  suffer 
severely  in  this  way  are  generally  those  of  highly  susceptible 
neurotic  temperament.  Frequently  they  have  j)reviously  suffered 
from  some  uterine  disturbance,  such  as  dysmenorrhoea.  The 
neurosis  may  be  aggravated  by  any  morbid  condition  of  the  uterus 
which  would  render  the  uterine  nerves  more  susceptible  to  irritation, 
whether  this  be  j)revious  endometritis  or  metritis,  inflammation  of 
cervix,  grave  displacement,  such  as  retroversion  or  retroflexion,  or 
any  other  condition.  For  instance,  vomiting  is  sometimes  relieved 
upon  the  replacement  of  a  retroverted  gravid  uterus-  But  such  a 
case  is  exceptional,  both  among  instances  of  retroversion  of  the 
gravid  uterus,  and  among  those  of  vomiting  of  pregnancy.  It  has 
been  alleged  that  the  paroxysms  of  vomiting  are,  in  some  cases  at 
any  rate,  coincident  with  the  uterine  contractions  which  occur 
during  pregnancy.  This  would  agree  with  the  fact  that  women  who 
suffer  from  spasmodic  dysmenorrhcea  are  specially  liable  to  vomiting. 
It  is  to  be  noted,  however,  that  as  the  contractions  become  more 
marked  toward  the  later  months  of  jDregnancy,  the  vomiting 
diminishes. 

In  some  instances  painful  emotion  or  sudden  mental  shock  is  the 
starting-point  of  a  very  severe  kind  of  vomiting.  It  has  been 
suggested  that  some  forms  of  acquired  or  congenital  malformations 
of  the  stomach  may  also  play  a  predisposing  part.     In  other  cases 


Disorders  of   Pregnancy.  457 

the  tendency  to  vomiting  due  to  various  stomach  disorders,  especi- 
ally the  dyspepsia  produced  by  alcoholism,  or  Bright's  disease,  is 
added  to  the  effect  of  pregnancy,  and  greatly  aggravates  it. 

In  some  rare  cases  in  which  the  vomiting  of  pregnancy  terminates 
fatally  necrotic  changes  in  the  cells  of  the  centre  of  the  liver 
lobules  (Whitridge  Williams)  and  of  the  secretory  tubules  of  the 
kidney,  similar  in  type  to  those  which  are  found  in  eclampsia,  have 
been  described  as  discovered  post  mortem.  On  this  ground  it  has 
been  supposed  that  such  fatal  cases  of  vomiting  are  altogether 
different  in  their  nature  and  causation  from  the  milder  degree  of 
the  vomiting  of  pregnancy.  It  may  be,  however,  that  even  in  such 
cases  the  same  causation  may  form  some  element  in  the  case ;  but 
that  there  is,  in  addition,  a  toxic  condition  of  the  blood,  the 
toxaemia  of  pregnancy  ;  and  that  this  determines  the  fatal  result. 

Symptoms  and  Course. — In  some  cases,  although  the  vomiting  is 
excessively  distressing,  yet  the  general  nutrition  does  not  seem  to 
suffer  much.  This  is  especially  the  case  when  the  vomiting  is  not 
continued  throughout  the  whole  day.  In  more  severe  cases  symp- 
toms of  starvation  appear.  The  patient  becomes  emaciated  and 
weak,  the  tongue  glazed  and  irritable,  the  urine  scanty,  the  breath 
foetid,  and  often  there  is  a  want  of  sleep.  In  the  later  stages 
elevation  of  temperature  or  delirium  may  occur.  In  some  cases  the 
urine  becomes  albuminous ;  and,  according  to  Whitridge  Williams, 
the  proportion  of  the  total  nitrogen  excreted  as  ammonia,  which 
normally  should  amount  to  about  4  or  5  per  cent.,  may  rise  to 
as  much  as  20,  30,  or  even  40  per  cent.  It  is  quite  possible,  how- 
ever, that  the  true  explanation  of  this  alteration  in  the  relative 
quantities  of  ammonia  and  urea  may  be  the  accompanying 
condition  of  starvation  of  the  patient  in  a  case  of  pernicious 
vomiting,  and  no  correct  deduction  can  be  drawn  as  to  the  nature 
of  the  vomiting  or  its  causation  from  the  ammonia  coefficient  of 
the  urine  alone.  The  depravation  of  the  blood  and  general  weakness 
predispose  to  septicaemia,  which  is  liable  to  arise  after  either  spon- 
taneous or  induced  abortion.  Spontaneous  abortion  is  apt  to  be 
deferred  until  the  patient  is  almost  moribund,  and  does  not  then 
save  her  life.  If  it  occurs  before  symptoms  are  very  grave,  she 
generally  quickly  recovers. 

Prognosis. — Cases  which  endanger  life  are  very  rare  in  comparison 
with  the  number  of  women  who  suffer,  but  they  are  not  absolutely 
so  excessively  uncommon.  McClintock  collected  nearly  50  fatal 
cases ;  Gueniot  4f5 ;  It.  Barnes  had  himself  seen  9.  When  the 
pulse  rises  above  120,  when  delirium  occurs,  and  haematemesis  or 
diarrhoea  supervenes  at  a  severe  stage,  the  danger  is  great. 


458  The  Practice  of   Midwifery. 

Treatment. — In  mild  cases,  in  which  simply  the  ordinary  morning 
sickness  is  unusually  troublesome,  it  is  important  that  the  patient 
should  take  a  little  food  before  getting  up.  This  relieves  the 
exhaustion  which  may  promote  the  instability  of  the  nerve  centres, 
and  gives  the  stomach  occupation  in  a  right  direction. 

Constipation,  when  it  exists,  should  be  treated.  When  there  is 
a  foul  tongue,  a  dose  of  calomel  occasionally  is  of  service,  and 
bismuth  with  bicarbonate  of  soda,  or  bicarbonate  of  potash  with 
calumba  and  hydrocyanic  acid  may  be  given  before  food.  Often  an 
acid  with  a  vegetable  bitter  after  food  ^  assists  digestion  and  relieves 
vomiting.  If  any  special  lesion,  such  as  granular  inflammation  of 
the  cervix,  exists,  the  effect  of  local  treatment  to  it  should  be  tried. 
Thus  occasional  painting  of  the  cervix  with  concentrated  tincture 
of  iodine  is  often  beneficial.  Retroversion  or  retroflexion  of  the 
gravid  uterus  should  be  remedied,  whether  there  is  vomiting  or  not. 
Drugs  innumerable  have  been  recommended,  and  not  uncommonly 
all  are  found  to  fail.  Among  these  may  be  mentioned  effervescing 
mixtures  with  hydrocyanic  acid,  pepsin  oringluvin  after  meals,  oxalate 
of  cerium,  which  may  be  given  in  doses  of  from  five  to  ten  grains, 
creosote,  tincture  of  nux  vomica,  vinum  ipecacuanhfe  in  doses  of  one 
minim  every  hour  or  every  two  hours,  tincture  of  iodine  in  minim 
doses,  comj)ound  pyroxylic  spirit  in  five-minim  doses,  caffeine, 
nitrite  of  amyl  by  inhalation.  Among  the  most  likely  to  be  useful 
are  remedies  which  are  found  to  be  of  value  in  sea-sickness,  such  as 
bromide  of  potassium  in  full  doses,  and  nitro-glycerine  in  tablets, 
containing  each  ^ho  gi'ain.  Iced  champagne  with  milk  is  some- 
times retained,  but  if  there  is  any  suspicion  of  tendency  to 
alcoholism,  recourse  to  alcohol  as  a  remedy  should  be  checked, 
since  it  aggravates  the  complaint. 

In  severe  cases  position  and  diet  should  be  specially  attended  to. 
The  patient  should  be  kept  recumbent,  and  liquid  nourishment 
should  be  given  at  short  intervals,  only  a  spoonful  at  a  time.  Iced 
milk  with  soda-water  or  barley-water,  or  meat  jelly,  may  be  tried. 
Brand's  essence  of  beef  is  often  retained  when  milk  is  rejected. 
Barff 's  kreochyle  is  also  valuable.  Being  pej)tonised,  it  is  quickly 
absorbed,  even  when  nothing  can  be  retained  long  in  the  stomach. 
Peptonised  milk  or  other  forms  of  predigested  food  may  also  be 
tried.  If  there  is  much  exhaustion  somatose  or  Peptone  Cornells  is 
valuable.  Fifteen  minims  of  tincture  of  opium,  given  by  rectum, 
or  a  small  subcutaneous  injection  of  morphia  and  atropia,  are  often 
useful ;  but,  with  a  patient  susceptible  to  morphia,  this  may  rather 
do  harm.     Sulphate  of  atropia,  ^q  grain,   given  by  subcutaneous 

1  Acid  Nitro-hydrochlor.  Dil.  TTLsv. ;  Tinct.  Gentian.  Co.  3j-  ;  Aq.  ad  Jj. 


Disorders  of   Pregnancy.  459 

injection,  sometimes  appears  to  be  of  more  use  than  any  other 
remedy.  In  other  cases  minute  doses  of  morphia  given  by  the 
mouth,  and  repeated  whenever  vomited,  prove  of  great  use. 
Counter-irritation  over  the  stomach  sometimes  does  good,  and 
some  recommend  Chapman's  spinal  ice-bag,  applied  to  the  cervical 
vertebrae.  The  patient  should  not  be  allowed  to  become  much 
emaciated  before  recourse  is  had  to  nutrient  enemata.  These 
should  either  consist  of  artificially  digested  food,  or  pancreatic 
extract  should  be  added  to  them  to  procure  digestion  in  the 
rectum.^ 

On  the  hypothesis  that,  in  the  pernicious  form  of  vomiting,  the 
cause  is  a  toxin  resulting  from  defective  metabolism,  treatment  by 
thyroid  extract  has  been  suggested,  and  favourable  results  have  been 
reported.  This  appears  worthy  of  trial,  especially  if  albuminuria 
is  present.  Good  results,  too,  may  be  obtained  by  the  transfusion 
of  saline  fluid  subcutaneously  or  by  the  bowel. 

The  most  radical  treatment  is  of  course  the  induction  of  abortion. 
But  before  having  recourse  to  this,  if  danger  is  not  too  extreme,  it 
is  often  worth  while  to  try  the  plan  recommended  by  the  late 
Dr.  Copeman,  of  Norwich,  namely,  dilatation  of  the  cervical  canal. 
If  the  cervical  canal  is  already  somewhat  patulous,  this  may  be 
effected  by  pressing  the  index-finger  into  it ;  if  not,  metallic  bougies 
may  be  passed  into  the  canal,  but  not  farther  than  just  up  to  the 
internal  os.  This  remedy  must  be  regarded  as  an  empirical  one. 
The  only  rational  explanation  of  it  is,  that  the  uterine  tension  acts 
especially  on  the  nerves  about  the  internal  os,  and  that  its  effect  is 
diminished  by  partial  dilatation  of  that  orifice.  Since  any  effectual 
dilatation  of  the  cervix  has  a  strong  tendency  to  bring  on  abortion, 
this  treatment  should  only  be  adopted  when  the  case  is  serious 
enough  to  justify  such  a  risk  ;  and  it  should  therefore  be  preceded 
by  a  consultation. 

Abortion  should  be  induced  only  when  the  mother's  life  is 
endangered.  It  is  often  necessary  to  tesist  the  desire  of  the 
patient  herself,  who  may  be  greatly  wearied  by  the  vomiting,  and 
perhaps  may  prefer  not  to  have  a  living  child.  If,  however,  the 
pulse,  the  tongue,  and  the  degree  of  emaciation  denote  danger, 
interference  should  not  be  put  off  too  long ;  otherwise  it  may  fail  to 
save  life,  and  the  patient  may  sink  from  exhaustion  or  septicaemia 
shortly  after  the  abortion  is  completed.     It  is,  of  course,  an  absolute 


1  Mix  equal  parts  of  hot  thick  water-gruel  and  cold  milk.  Add  Benger's  Liquor 
I'ancreaticus  3j.i  and  bicarbonate  of  soda,  gr.  v.  to  "^iv.  of  the  mixture,  with  which 
an  egg  may  also  be  beaten  up.  If  these  enemata  are  not  retained,  use  solid  peptone 
suppositories. 


460  The  Practice  of   Midwifery. 

rule  that,  for  the  protection  of  the  medical  man  himself,  a  consul- 
tation should  be  held  before  this  step  is  decided  uj)on.  If  the 
operation  is  not  undertaken  too  late,  cessation  of  the  vomiting 
generally  soon  follows,  and  may  be  attained  even  before  the  uterus 
is  completely  emptied.  The  method  of  procedure  in  inducing 
abortion  will  be  described  in  Chapter  XXXI. 


Other  Digestive  Disturbances. — Besides  vomiting,  other  forms 
of  digestive  disturbance,  such  as  pyrosis,  heartburn,  and  flatulence, 
are  common.  Occasionally  diarrhoea  is  set  up,  and  this  may  call 
for  treatment,  especially  on  account  of  its  tendency  to  lead  to 
abortion  or  premature  labour.  The  more  common  tendency  is  to 
constipation,  which  is  partly  due  to  the  enlarged  uterus  mechani- 
cally interfering  with  intestinal  movements.  Laxatives  will  be 
required,  especially  if  the  patient  suffers  from  varicose  veins,  or 
swelling  of  the  feet,  conditions  which  are  aggravated  by  constipa- 
tion. The  pill  recommended  at  p.  406  may  be  taken  at  night  when 
required,  or  a  moderate  dose  of  the  compound  liquorice  powder, 
or  a  small  dose  of  saline.  Sometimes  enemata  are  found  preferable 
to  aj)erients. 

Salivation. — Salivation  is  a  somewhat  rare  complication,  probably 
of  nervous,  but  possibly  of  toxic,  origin.  Sometimes  it  is  not  only 
very  annoying  to  the  patient,  but  exhausting  by  its  profusion.  It 
may  be  combined  with  vomiting,  and,  like  vomiting,  it  is  generally 
most  marked  in  the  second,  third,  and  fourth  months.  It  is  apt  to 
resist  remedies.  Astringent  mouth  washes,  tannin  lozenges,  and 
the  like,  may  be  tried  ;  also  iodide  of  potassium,  for  its  influence 
upon  gland  activity,  or  belladonna,  for  its  special  effect  on  the 
salivary  glands.  Subcutaneous  injections  of  atropin  near  the 
glands  have  been  recommended. 

By  those  who  believe  that  salivation  is  another  manifestation 
of  toxic' poisoning  a  pure  milk  diet  with  intestinal  antiseptics  is 
advocated. 

Gingivitis. — Congestion  and  hypertrophy  of  the  gums  occurs  in 
some  50  to  60  per  cent,  of  pregnant  women,  both  primiparae  and 
multiparee.  The  condition  is  one  of  simple  hyperplasia,  but  may 
in  rare  cases  become  very  marked  and  give  rise  to  a  good  deal  of 
discomfort  and  bleeding.  The  use  of  an  antiseptic  astringent 
mouth  wash  is  indicated,  and  at  times  the  treatment  of  the 
hyper trophied  tissues  with  the  cautery. 


Disorders  of   Pregnancy.  461 

Anaemia. — ^In  the  poorly  developed  and  ill  nourished  a  certain  degree 
of  anaemia  is  the  rule  in  pregnancy,  especially  when  the  children  follow 
one  another  in  rapid  succession,  or  if  nutrition  is  interfered  with 
by  vomiting  and  other  digestive  disturbances.  Anaemic  bruits 
are  heard  in  the  heart  and  arteries,  and  the  uterine  souffle  becomes 
unusually  loud.  The  number  of  red  corpuscles  and  the  proportion 
of  albumen  in  the  blood  diminish,  while  the  number  of  white 
corpuscles  and  the  amount  of  fibrin  and  water  increase.  The 
watery  condition  of  the  blood  may  lead  to  oedema,  in  the  absence 
of  any  albuminuria.  This  oedema  extends  to  face  and  upper  parts 
of  the  body,  but  is  much  more  marked  in  parts  where  the  effect  of 
pressure  on  the  veins  is  also  operative,  that  is  to  say,  in  the  legs 
and  vulva.  In  rare  cases  the  anaemia  assumes  the  character  of 
"progressive  pernicious  anaemia,"  and  tends  to  a  fatal  result. 
Examination  of  the  blood  then  shows  marked  diminution  in  the 
number  of  the  red  cells  and  the  presence  of  numerous  irregular  and 
nucleated  red  corpuscles.  A  very  large  proportion  of  such  cases 
have  ended  in  death,  even  when  pregnancy  has  been  brought  to  a 
premature  close  spontaneously  or  artificially. 

Treatment. — The  first  principle  in  treatment  is  to  improve  the 
general  condition  by  nutritious  and  easily  digestible  diet,  especially 
meat,  when  it  can  be  taken.  When  practicable,  the  digestive 
powers  should  also  be  stimulated  by  a  due  amount  of  fresh  air  and 
gentle  exercise.  Any  oral  sepsis  should  receive  special  attention. 
Iron  should  be  given  without  hesitation  ;  reduced  iron,  if  the  vege- 
table salts  are  not  easily  tolerated.  In  cases  in  which  iron  fails 
to  do  good,  arsenic,  manganese,  or  phosphorus  in  addition  has  been 
recommended.  In  rare  and  extreme  cases,  induction  of  abortion 
or  premature  labour  may  be  called  for.  When  the  anaemia  appears 
to  have  the  progressive  or  pernicious  character,  this  step  should 
not  be  too  long  deferred. 

Neuralgia. — Neuralgic  pain  is  common  in  pregnancy,  and  may 
be  regarded  as  partly  a  reflex  neurosis,  partly  the  result  of  anaemia 
or  impaired  nutrition,  or  the  result  of  the  presence  of  toxic  sub- 
stances from  tissue  metabolism  in  the  blood.  In  the  case  of  tooth- 
ache, it  often  results  from  the  fact  that  caries  of  the  teeth  is  more 
liable  to  occur  during  pregnancy.  Besides  faceache,  the  most 
common  neuralgias  are  headache  and  mammary  and  intercostal 
pain. 

Treatment. — In  the  case  of  carious  teeth,  extraction  or  stopping, 
according  to  circumstances,  should  not  be  deferred  on  account  of 
the  pregnancy.     For  simple  neuralgia,    iron  and  quinine   are  the 


462  The   Practice  of   Midwifery. 

most  valuable  drugs.  The  latter  may  often  be  given  in  large 
doses.  Opium  and  morphia  should  be  avoided  as  far  as  possible. 
For  the  immediate  relief  of  toothache  or  facial  neuralgia,  tincture 
of  gelsemium  may  be  given  in  doses  of  ten  or  fifteen  minims. 
Outward  applications,  such  as  linimentam  aconiti,  are  often  useful. 

Cough,  Dyspnoea,  Palpitation,  and  Syncope.  —  Cough  in 
pregnancy  is  frequently  of  a  spasmodic  and  reflex  character,  like 
that  which  occurs  in  hysterical  subjects.  Dyspnoea  and  palpita- 
tion, in  the  absence  of  any  cardiac  affection,  may  be  partly  reflex, 
and  partly  the  result  of  anaemia.  Dyspnoea  in  the  later  months 
generally  depends  in  part  upon  the  downward  movement  of  the 
diaphragm  being  limited,  although  the  actual  capacity  of  the  chest 
is  now  known  not  to  be  diminished  in  pregnancy.  Syncope  in 
pregnancy  often  does  not  mean  actual  failure  of  the  heart,  but  is 
rather  of  the  nature  of  the  apparent  fainting  which  is  closely  allied 
to  hysteria.  There  is  a  semi-unconscious  condition,  which  may 
last  for  a  considerable  time,  but  no  grave  alteration  of  the  pulse. 

Treatment. — If  drugs  are  required  for  the  cough,  antispasmodics, 
such  as  belladonna  and  bromide  of  potassium,  should  be  given. 
For  the  other  neuroses  above  mentioned,  good  diet  and  tonic 
treatment,  especially  iron,  are  the  chief  remedies.  If  there  is 
dyspnoea  care  should  be  taken  that  the  clothing  is  loose  enough. 
For  attacks  of  "  fainting,"  alcohol  should  be  avoided,  but  ether  or 
aromatic  spirit  of  ammonia  may  be  given.  Anti-hysterical  remedies, 
such  as  valerian,  may  also  be  tried. 

Eruptions. — Various  eruptions  appear  occasionally  to  have  a 
causal  relation  with  pregnancy,  as  they  do  sometimes  with  disturb- 
ances of  uterus  and  ovaries  apart  from  pregnancy.  The  chief  of 
these  are  acne,  eczema,  herpes,  and  urticaria.  A  special  title  of 
"  herpes  gestationis  "  has  been  given  to  an  eruption  of  groups  of 
vesicles  on  the  limbs  and  buttocks,^  which  often  recurs  in  successive 
pregnancies.  A  more  severe  form  of  this,  becoming  pustular, 
probably  of  septic  origin,  and  in  several  cases  ending  fatally, 
"impetigo  herpetiformis,"  has  been  described  by  Hebra.^  The 
treatment  of  these  eruptions  must  be  conducted  on  general 
principles. 

Pruritus. — In  rare  cases  general  pruritus  of  the  skin  exists 
as  a  neurosis.  Pruritus  of  the  vulva  is  comparatively  common. 
It  is  promoted  by  the  local  venous  congestion,  but  most  frequently 

1  Bulkley,  Amer.  Journ.  of  Obstet.,  Vol.  VI. 

2  Wien.  Med,  Woch.,  1872,  No.  48. 


Disorders   of   Pregnancy.  463 

has  a  starting  point,  either  in  some  eczema  of  the  part  affected, 
or  in  the  irritation  of  an  acrid  leucorrhceal  discharge  from  cervix 
or  vagina. 

Treatment. — In  pruritus  of  the  vulva,  any  source  of  leucorrhcea 
should  be  treated,  and  the  syringe  used  frequently  to  wash  away 
the  discharge.  The  bowels  should  be  kept  acting  freely.  As 
lotions  to  be  applied  directly  to  the  affected  surface,  solution  of 
borax  (gr.  x.  ad  5].),  the  liq.  plumbi  subacetatis  dil.,  solution  of 
carbolic  acid  (gr.  ij.  to  iv.  ad  5]'.),  and  especially  one  of  perchloride 
of  mercury  (gr.  ij.  ad  3]',)  may  be  tried.  Glycerine  (5J.  ad  5].), 
and  hydrochlorate  of  morphia  (gr.  ij.  ad  3J.),  or  dilute  hydrocyanic 
acid  (5SS.  ad  3J.),  or  a  combination  of  the  two,  may  also  be  added 
for  greater  sedative  effect.  When  the  irritating  effect  of  leucorrhcea 
seems  to  be  the  chief  cause  of  trouble,  the  vulva  may  be  pro- 
tected with  vaseline  to  which  acetate  of  lead  (gr.  xxx.  ad  §j.)  and 
hydrochlorate  of  morphia  (gr.  x.  ad  5J.)  may  be  added.  An 
ointment  of  cocain,  creosote,  and  conium  often  gives  relief. 

Chorea. — Chorea  is  not  a  common  complication  of  pregnancy, 
but,  after  the  age  of  childhood,  it  is  relatively  much  commoner  in 
conj  unction  with  pregnancy  than  apart  from  it,  so  that  there  is  no 
doubt  that  pregnancy  is  a  strong  predisposing  cause.  Hence  the 
occurrence  of  chorea  in  a  young  woman  should  always  raise  the 
question  whether  pregnancy  exists.  Not  only  does  pregnancy 
predispose  to  chorea,  but  the  very  grave  or  fatal  cases  of  chorea 
recorded  have  been  frequently  those  associated  with  pregnancy ; 
and,  in  general,  with  this  complication,  the  disease  is  much  more 
likely  to  prove  very  severe  as  regards  the  violence  of  the  motions, 
to  lead  to  bodily  wasting  or  paresis,  and  to  be  accompanied  with 
mental  disturbance,  leading  on,  in  some  cases,  even  to  mania.  It 
is  therefore  to  be  regarded  much  more  seriously  than  the  ordinary 
chorea  of  children. 

The  immediate  and  essential  cause  of  the  chorea  of  pregnancy, 
as  of  chorea  in  general,  is  not  yet  fully  ascertained.  But  it  cannot 
be  doubted  that  pregnancy  promotes  the  disease  in  two  ways,  first, 
as  a  cause  of  reflex  irritation,  and  secondly,  by  impoverishment  of 
the  blood.  The  element  of  mental  emotion,  well  known  as  an 
occasional  starting  point  of  chorea,  is  also  added  in  some  cases,  as 
when  an  unmarried  girl  has  become  pregnant.  Those  who  suffer 
from  chorea  in  pregnancy  are  generally  young  primiparge  (59  per  cent, 
of  Buist's  cases),  who  have  either  suffered  from  the  disease  as 
children,  or  have  a  hereditary  tendency  to  neuroses.  The 
associations  with  rheumatism,    with  a  systolic  cardiac  bruit,  and 


464  The  Practice  of   Midwifery. 

with  vegetations  on  the  cardiac  valves,  found  in  fatal  cases,  have 
been  noticed  in  the  case  of  the  chorea  of  pregnancy,  as  in  that  of 
ordinary  chorea. 

The  disease  usually  commences  in  the  first  half  of  pregnancy, 
about  the  third  or  fourth  month;  occasionally  it  ceases  during  the 
course  of  the  pregnancy,  but  more  commonly  it  continues  until 
the  onset  of  labour. 

Prognosis. — Spiegelberg^  gives  the  mortality  as  23  out  of  84^ 
cases,  or  27  per  cent. ;  but  it  must  be  remembered  that  slight 
cases  are  not  so  likely  to  have  been  recorded  as  the  severe. 
Schrock^  has  collected  154  cases  with  a  mortality  of  22  per  cent.  ; 
Buist^  255  cases  with  a  mortality  of  17'5  per  cent.;  Barnes^  56 
cases  with  a  mortality  of  30  per  cent. ;  Wall  and  Andrews  ^  40  cases 
treated  at  the  London  Hospital  with  a  mortality  of  12" 5  per  cent. 
Of  29  consecutive  cases  at  Guy's  Hospital  3  died.  French ' 
and  Hicks  lay  great  stress  upon  the  prognostic  importance  of  fever, 
and  maintain  that,  if  no  other  cause  can  be  found  for  the  fever, 
the  outlook  is  very  grave.  When  severe,  the  disease  has  a  tendency 
to«  produce  abortion  or  premature  labour.  In  many  instances 
recovery  has  quickly  followed,  but,  in  a  notable  proportion,  delivery 
has  only  occurred  at  an  extreme  stage,  and  death  has  followed 
shortly  after.  Death  of  the  foetus  often  occurs,  and  is  a  cause  of 
the  occurrence  of  premature  labour.  In  Buist's  cases,  spon- 
taneous abortion  or  premature  labour  occurred  in  17*6  per  cent. ; 
in  Barnes'  cases,  in  32  per  cent. ;  in  Wall  and  Andrews'  cases,  in 
only  12'5  per  cent.,  but  in  another  10  per  cent,  of  these  abortion 
was  induced. 

Treatment. — Chorea  during  pregnancy  is  less  influenced  than 
usual  by  drugs.  The  most  important  point  is  to  maintain  nutri- 
tion and  use  tonic  treatment,  especially  iron  and  arsenic.  When 
movements  are  very  violent,  direct  sedatives  may  be  called  for, 
such  as  chloral,  chloralamide,  or  even  inhalation  of  chloroform. 
When  danger  is  indicated  by  great  emaciation,  rapid  pulse,  and 
high  temperature,  when  there  is  notable  muscular  paresis,  or 
mental  disturbance  so  great  as  to  threaten  mania,  it  is  justifiable 
to  induce  artificial  abortion  without  waiting  till  it  is  too  late  to  cure. 

At  the  same  time  it  must  be  remembered  that  the  results  from 

1  Lehrbuch  der  Geburtshiilfe. 

2  Eighty  of    these    are    taken    from   Schwechten's  dissertation,    "  Ueber   Chorea 
Gravidarum,"  Halle,  1876. 

3  Ueber  Chorea  Gravidarum,  I.  D.  Konigsberg,  1898. 

^  "Chorea  Gravidarum,"  Trans.  Obst.  Soc,  Edinburgh,  1892. 
s  Trans.  Obst.  Soc,  London,  1869,  Vol.  X.,  p.  U7. 

6  Journ.  of  Obst.  and  Gyn.  Brit.  Emp.,  June,  1903,  Vol.  III.,  No.  6,  p.  5-10. 

7  French  and  Hicks,  Practitioner,  August,  1906. 


Disorders   of   Pregnancy.  465 

the  induction  of  abortion  are  not  at  all  good.  Thus  induced  abortion 
and  induced  premature  labour  was  followed  by  death  in  no  less  than 
43  per  cent,  of  the  cases  in  Buist's  series.  This  mode  of  treat- 
ment is  very  seldom  needed,  and  it  is  indeed  doubtful  if  it  has 
much  influence  in  saving  the  life  of  the  patient. 

Hysteria.— In  patients  subject  to  hysterical  manifestations, 
these  are  often  increased  during  pregnancy,  and  more  especially 
at  the  time  of  labour,  under  the  influence  of  pain. 

The  Insanity  of  pregnancy  will  be  considered  in  conjunction 
with  puerperal  insanity,  the  latter  being  the  more  common  affection. 


Albuminueia  and  Puerperal  Convulsions,  or  Eclampsia. 

The  occurrence  of  albuminuria  during  j)regnancy  has  been 
specially  considered  in  reference  to  its  connection  with  puerperal 
convulsions.  It  was  first  pointed  out  by  Lever  in  1842  ^  that, 
in  the  great  majority  of  cases  of  puerperal  convulsions,  albumen  in 
considerable  quantity  is  present  in  the  urine.  The  view  that  such 
convulsions  are  ursemic  in  character  then  generally  gained  accept- 
ance. Of  late,  however,  some  observers  have  endeavoured  to  show 
that  albuminuria  in  pregnant  and  parturient  women  is  compara- 
tively common,  while  eclampsia  is  very  rare,  and  hence  have 
depreciated  the  importance  of  the  albuminuria  as  indicating  the 
probable  imminence  of  convulsions.  The  importance  of  urgemia  in 
the  causation  of  eclampsia  has  also  been  controverted,  on  the 
ground  that  convulsions  sometimes  occur  without  albuminuria, 
and  that,  in  other  cases,  the  albuminuria  only  appears  after  the 
convulsions,  the  urine  before  the  fits,  or  after  the  first  fit,  being 
free  from  albumen. 

Albuminuria. — The  pathology  of  the  albuminuria  will  be 
considered  in  the  first  instance,  and  that  of  the  convulsions 
afterwards. 

Causation. — Several  different  theories  have  been  propounded  as 
to  the  causation  of  the  albuminuria.  These  are  not  necessarily  to 
be  regarded  as  rival  explanations,  for,  while  some  of  them  seem  to 
be  inadequate  taken  by  themselves,  it  is  probable  that,  in  many 
cases,  two  or  more  causes  combine  to  influence  the  kidneys. 

1.  The  first  assigned  cause  is  pressure  upon  the  renal  veins 
from  the  gravid  uterus,  producing  some  venous  congestion  in  the 

1  Guy's  Hosp.  Reports,  1842. 

M.  30 


466  The  Practice  of   Midwifery. 

kidneys.  It  is  not  a  sufficient  cause  by  itself.  It  is  true  that 
albuminuria  may  be  produced  by  pressure  of  an  ovarian  tumour. 
But  this  does  not  occur  till  the  tension  is  greater  than  is  usual  in 
pregnancy,  and  the  albuminuria  is  generally  a  passive  transudation 
only,  disappearing  when  pressure  is  taken  off,  while  there  is 
abundant  evidence  that,  in  the  marked  albuminuria  of  pregnancy, 
there  are  actual  changes  in  the  kidneys.  Albuminuria  may  also 
occur  in  the  early  months,  before  pressure  on  the  renal  veins  can 
exist. 

2.  The  second  cause  is  also  a  mechanical  one,  namely,  the 
pressure  of  the  uterus  upon  the  ureters.  In  consequence  of  this, 
the  kidneys  will  have  to  secrete  against  a  higher  pressure  than 
usual,  and  may  find  their  task  therefore  more  difficult.  This  cause 
may  operate  while  the  uterus  is  still  mainly  in  the  pelvis.  There 
is  some  direct  evidence  that  this  is  a  vera  causa,  for  out  of  32  fatal 
cases  of  eclampsia  Lohlein  found  that  in  8,  or  25  per  cent.,  dilata- 
tion of  one  or  both  ureters  was  recorded  at  the  autopsy.  Herzfeld, 
in  463  cases  of  eclampsia,  found  dilatation  of  both  ureters  in  22  per 
cent.^ 

A  further  argument  adduced  for  the  conclusion  that  mechanical 
pressure  in  one  or  both  of  these  modes  is  often  an  element  in  the 
case  is  the  fact  that  albuminuria  and  eclampsia  are  much  commoner 
in  primiparae,  in  whom  the  tension  of  the  abdominal  walls  is  greater. 
Thus  from  60  to  80  per  cent,  of  all  cases  of  eclampsia  occur  in 
primiparae.  There  is,  however,  as  we  shall  see,  another  possible 
explanation  of  this  fact.  Moreover,  twin  pregnancy  and  hydramnios 
are  also  predisposing  causes.  Twin  pregnancy  has  been  noted  in 
from  5  to  8  per  cent,  among  cases  of  eclampsia,^  whilst  among  all 
labours  its  proportion  is  only  from  "9  to  1*5  per  cent. 

3.  The  third  cause  is  the  increased  work  thrown  u]3on  the  kidneys 
during  pregnancy  by  their  having  to  excrete  the  waste  products 
resulting  from  the  increased  tissue  metabolism  of  the  mother  and 
that  of  the  foetus.  Although  the  bulk  of  the  latter  is  small  in  pro- 
portion to  the  body,  yet  activity  of  growth  must  be  accompanied  by 
active  formation  of  waste  products,  and,  if  the  kidneys  are  naturally 
weak,  and  barely  equal  to  their  work  before,  this  addition  may 
just  disturb  the  balance,  especially  when  added  to  mechanical 
causes  of  embarrassment.  Evidence  in  favour  of  the  operation  of 
this  cause  is  the  fact  that  both  albuminuria  and  eclampsia  have 

1  Zentralbl.  f.  Gyn.,  1901,  No.  40. 

2  Cassamajor,  "Contribution  a  I'Etude  de  TEclampsie  Puerperale  d'apres  une 
Statistique  de  la  Clinique  de  1872—1892,"  D.I.,  Paris,  1892;  Olshausen,  "  Ueber 
Eklampsie,"  Volkroann's  Sammlung,  1891,  No.  39. 


Disorders  of   Pregnancy.  467 

been  found  to  subside  after  the  death  of  the  foetus  and  before  its 
expulsion. 

If,  on  account  of  any  disturbance  in  the  function  of  the  liver  or 
other  blood  glands,  metabolism  is  imperfect,  intermediate  products 
may  result  more  toxic  than  the  normal  ultimate  products.  Such 
toxins  circulating  in  the  blood  may  cause  further  damage  to  the 
glands  at  fault  as  well  as  to  the  kidneys.  This  in  its  turn  will  lead 
to  a  further  retention  of  them  in  the  mother's  tissues,  resulting  in 
a  condition  of  so-called  auto-intoxication.  In  favour  of  this  view  is 
the  fact  that  degenerative  changes  are  found  in  the  liver  cells  as 
well  as  in  the  kidneys. 

4.  The  fourth  cause  is  the  increased  arterial  tension  which  is 
usual  in  pregnancy.  Considerable  disturbances  of  the  kidney 
circulation  probably  also  occur  during  labour  pains.  Possibly  this 
is  the  explanation  of  the  greater  frequency  with  which  foreign 
observers  have  discovered  a  slight  degree  of  albuminuria  during 
labour  compared  with  that  noted  in  the  ninth  month  of  preg- 
nancy (see  below).  Such  albumen,  when  only  present  in  very 
small  quantity,  and  without  any  general  oedema  or  constitutional 
symptoms,  is  probably  only  a  passive  transudation. 

5.  The  fifth  possible  cause  is  one  suggested  by  Tyler  Smith, 
namely,  a  reflex  nervous  influence  starting  from  the  pregnant 
uterus  as  a  source  of  irritation,  and  disturbing  the  circulation  or 
secretion  of  the  kidneys,  as  those  of  the  salivary  and  thyroid 
glands  are  in  some  cases  disturbed.  This  it  is  difficult  or 
impossible  to  verify,  but  it  does  not  seem  an  improbable  cause, 
since  there  is  a  close  nervous  connection  between  the  kidneys  and 
pelvic  organs,  as  is  often  shown  by  the  sudden  copious  secretion 
of  urine  in  hysterical  women. 

6.  A  theory  of  the  causation  of  the  form  of  albuminuria  associated 
with  eclampsia  is  that  it  is  dependent  upon  a  special  form  of  micro- 
organism. Blanc ^  made  culture  of  a  micrococcus  from  the  kidneys 
of  eclamptic  patients,  and  stated  that  the  product,  if  injected 
into  rabbits,  gave  rise  not  only  to  albuminuria,  but  directly  to 
convulsions.  Gerdes^  found  a  bacillus  which  he  regarded  as  the 
cause  of  eclampsia  in  the  blood  and  in  various  organs,  but  most 
in  the  placenta.  Other  observers,  however,  consider  this  to  be 
only  the  proteus  vulgaris  and  to  be  of  post-mortem  origin. 
Lermovitsch  "^  found  a  round  or  oval  organism  in  the  blood  of 
44   eclamptic   patients,    cultures   of   which,  injected    into  guinea- 


1  Zeitschr.  t  Geb.  und  Gyniik.,  XXXIII.,  p.'i). 

2  Deutsch.  Med.  Wochenschr. ,  1892,  XVIIJ.,  p.  26, 
8  Lermovitsch,  Zentral?jl.  f.  Gyniik. ,  1899,  No.  46. 


30- 


468  The   Practice  of   Midwifery. 

pigs  and  rabbits,  caused  haemorrhagic  endometritis,  anaemia,  and 
tetanic  spasms.  Most  observers  have  found  that  no  specific 
organisms  can  be  cultivated  from  either  the  blood  or  the  urine, 
and  this  theory  is  therefore  probably  erroneous. 

7.  The  most  recent  theory  is  that  the  toxaemia  which  produces 
both  the  changes  in  the  kidneys  and  the  eclampsia  is  the  result 
of  the  action  of  certain  ferments  in  the  placenta,  the  toxins  from 
which  pass  into  the  general  circulation  and  set  up  chemical  changes 
in  other  organs  of  the  body.  On  this  ground  the  early  emptying 
of  the  uterus  is  advocated  as  a  remedy. 

Frequency  of  Albuminuria. — Eather  contradictory  accounts  have 
been  given  as  to  the  frequency  with  which  albuminuria  exists  in 
pregnant  women,  without  any  other  morbid  sign  appearing.  Some 
foreign  observers  make  it  appear  to  be  a  common  occurrence.  Thus 
Blot,  Litzmann,  Petit,  and  Hypolitte  have  published  observations 
in  which  they  found  albumen  in  the  urine  of  more  than  20  per 
cent,  of  women  during  or  just  after  labour.  During  the  ninth 
month,  before  the  onset  of  labour,  albumen  was  found  in  about 
14  per  cent. 

On  the  other  hand,  albuminuria,  which  can  be  detected  in  the 
ordinary  way  by  heat  and  nitric  acid,  does  not  seem  so  common 
in  this  country.  Out  of  200  cases  in  the  Guy's  Hospital  Charity, 
in  which  the  urine  was  tested  about  the  time  of  labour,  albumen 
was  found  in  only  four,  and  two  of  these  appeared  to  be  cases  of 
chronic  Bright's  disease.  The  explanation  may  lie  in  the  fact, 
that  the  foreign  observers  used  more  delicate  tests,  and  so  recorded 
very  slight  traces  of  albumen.  Such  a  degree  of  albuminuria 
stands  widely  apart  from  that  usually  associated  with  eclampsia, 
for  in  that  albumen  is  generally  present  in  large  proportion. 
According  to  Little,  however,  in  1,000  jD^egnant  women  whose 
urine  was  examined  in  the  Johns  Hopkins  Hospital,  a  considerable 
proportion  of  albumen,  together  with  tube-casts,  was  recorded  in 
7*3  per  cent,  of  the  cases. 

It  is  of  course  to  be  borne  in  mind  that,  if  albumen  be  found 
in  urine  passed  in  the  ordinary  way,  the  observation  must  be 
confirmed  by  testing  some  which  has  been  withdrawn  by  catheter  ; 
otherwise  the  albumen  may  be  due  to  some  admixture  of  vaginal 
secretion.  It  is  probable  that  slight  traces  of  albumen  are  often 
due,  not  to  any  kidney  affection,  but  to  a  slight  catarrh  of  the 
bladder,  which  is  not  uncommon  in  pregnancy.  In  other  cases, 
especially  if  occurring  quite  at  the  end  of  pregnancy,  or  during 
labour  only,  they  may  result  from  slight  mechanical  transudation 
under  pressure  without  any  nephritis. 


Disorders  of   Pregnancy. 


469 


In  considering  the  albuminuria  of  pregnancy  three  separate 
conditions  must  be  recognised.  The  presence  of  the  albumen  may 
be  due  to  the  fact  that  a  woman  who  is  the  subject  of  chronic 
Blight's  disease  becomes  pregnant,  it  may  appear  in  the  urine  in 
the  early  months  of  pregnancy  and  be  associated  with  the  so-called 
kidney  of  pregnancy,  or  it  may  appear  for  the  first  time  late  in 
pregnancy  or  during  labour  in  association  with  the  onset  of  an 
attack  of  eclampsia. 

Chronic  Bright's  disease  is  usually  aggravated  by  the  occurrence 


Pig.  267. — Kidney  of  pregnancy  from  a  patient  with  albuminuria  and 
hydatidiform  mole  dying  from  hfemorrhage.  Cloudy  swelling  and 
coagulation  necrosis  of  the  epithelium  of  the  convoluted  tubules  is 
present  (see  Fig.  286). 


of  pregnancy,  but,  as  a  rule,  the  patient  does  not  develop  eclampsia, 
and  the  case  runs  a  course  similar  to  that  of  an  ordinary  instance 
of  this  disease. 

The  second  class  of  case,  in  which  the  albumen  appears  usually 
about  the  middle  of  the  pregnancy,  presents  much  the  same 
symptoms  as  those  of  an  ordinary  case  of  acute  kidney  disease.  In 
most  instances  the  patients  have  previously  been  perfectly  healthy, 
and  the  albuminuria  is  accompanied  by  oedema  and  the  presence  of 
renal  tube  casts  and  blood  in  the  urine,  a  condition  which  by  some 
authors  is  called  the  chronic  renal  disease  of  pregnancy.      This 


470  The   Practice  of   Midwifery. 

variety  of  kidney  disease  rarely  leads  to  the  development  of 
eclampsia,  but  not  uncommonly  there  is  a  history  of  an  attack  of 
eclami)sia  in  a  previous  pregnancy.-^ 

Herman^  has  shown  that  in  the  albuminuria  of  pregnancy  three 
different  types  of  kidney  may  be  met  with  :  first,  kidneys  showing 
disease  such  as  may  occur  apart  from  pregnancy ;  secondly, 
conditions  very  closely  resembling  those  of  ordinary  acute  nephritis  ; 
thirdly,  kidneys  presenting  macroscopically  but  little  change,  but  on 
microscopic  examination  showing  evidence  of  acute  degenerative 
processes,   the   typical   kidneys   of   eclampsia    (see  p.  480). 

As  French  and  others  have  pointed  out,  a  very  close  comparison  can 
be  drawn  between  the  kidney  changes  occurring  in  cases  of  scarlet 
fever  and  those  occurring  during  pregnancy.  Just  as  there  are 
cases  of  scarlatinal  nephritis  in  which  cedema  is  entirely  absent, 
and  uraemia  is  the  first  symptom  to  attract  attention,  while  in  other 
cases  cedema  without  ursemia  is  a  marked  feature,  so  in  cases  of 
the  albuminuria  of  pregnancy  oedema  may  be  marked  without  the 
occurrence  of  eclampsia,  and,  on  the  other  hand,  eclampsia  may  occur 
suddenly  with  little  or  no  oedema. 

The  changes  in  the  kidneys,  too,  in  the  two  cases,  are  very  com- 
parable, and  may  vary  from  slight  congestion  to  the  most  acute 
degenerative  processes  afl'ecting  large  areas  of  the  kidney  substance. 
We  may  therefore  conclude  that  the  difference  is  one  of  degree  only 
between  the  cases  in  which  albuminuria  occurs  early  in  pregnancy, 
with  a  good  deal  of  oedema,  and  those  in  which  eclampsia  occurs 
late  in  pregnancy,  with  little  or  no  oedema. 

A  recent  nejjhritis,  the  result  of  pregnancy,  is  said  to  be 
distinguished  from  a  chronic  Bright's  disease,  upon  which  pregnancy 
has  supervened,  in  the  relative  proportion  of  serum  albumen  and 
paraglobulin  in  the  urine.  In  chronic  Bright's  disease,  the  greater 
portion  of  the  precipitate  consists  of  serum  albumen,  in  eclamptic 
patients,  of  paraglobulin.^ 

Symptoms  and  Course. — The  nephritis  associated  with  eclampsia 
appears  in  the  majority  of  cases  to  be  a  quite  recent  attack. 
Usually  only  a  slight  amount  of  general  oedema,  which  com- 
monly has  escaped  notice,  precedes  the  convulsive  attack.  In 
49  per  cent,  of   French's  cases  there  was  no  oedema  at  all,  and 

1  French,  Goulstonian  Lectures,  Brit.  Med.  Journ.,  May,  1908. 

2  Herman,  AUbutt's  Syst.  Med.,  1899,  Vol.  VII.,  p.  810. 

s  Treat  the  urine  with  a  saturated  solution  of  magnesium  sulphate,  and  filter.  This 
precipitates  the  paraglobulin  only,  which  remains  upon  the  filter.  The  serum  albumen 
in  the  filtrate  is  precipitated  by  heat.  The  residue  on  the  filter  is  dissolved  in  warm 
distilled  water,  and  precipitated  again  by  heat.  The  relative  quantities  can  thus  be 
compared.  See  Maguire,  Lancet,  1886,  Vol.  IL,  d.  524  ;  Ralfe,  Diseases  of  Kidneys, 
p.  107. 


Disorders  of   Pregnancy.  471 

in  35  per  cent,  there  was  only  slight  oedema  of  the  face  and  ankles. 
But  women  who  have  had  eclampsia  in  their  first  pregnancy 
sometimes  have  a  recurrence  or  increase  of  albuminuria  in 
successive  pregnancies,  and  the  tendency  of  the  nephritis  of 
pregnancy,  when  thus  chronic  or  repeated,  seems  to  be  towards  the 
production  of  the  granular  kidney  of  interstitial  nephritis.  The 
affection  of  the  eyes  which  is  common  in  such  cases  confirms  this 
conclusion.  Eetinal  haemorrhages  and  white  spots  of  retinitis  are 
seen,  similar  to  those  usually  associated  with  chronic  interstitial 
nephritis.  Pre-existing  Bright's  disease  is  generally  aggravated  by 
pregnancy.  Frequently  the  extent  of  the  oedema  indicates  that  the 
interstitial  nephritis,  if  any,  which  exists,  is  complicated  by  more  or 
less  acute  tubal  nephritis.  The  oedema  is  also  aggravated  by  the 
tendency  to  hydremia  usual  in  pregnancy,  and  also  by  the  effect  of 
pressure.  Hence  it  sometimes  becomes  very  extreme  in  the  lower 
limbs,  vulva,  and  lower  part  of  abdomen.  A  very  marked  oedema 
of  the  vulva  usually  means  albuminuria,  and  not  merely  the 
effect  of  pressure. 

The  milder  symptoms  usual  in  the  nephritis  of  pregnancy  are 
headache,  sleeplessness,  dizziness,  and  vomiting.  There  is  an 
unusual  proneness  to  the  diseases  of  the  puerperal  state,  such  as 
septicaemia,  cellulitis,  and  mania,  and  probably  also  to  jjost-partum 
haemorrhage. 

Besides  eclampsia  and  impairment  of  sight,  the  nephritis  of 
pregnancy  involves  another  danger,  namely,  that  of  paralysis. 
Paraplegia,  hemiplegia,  and  facial  paralysis  are  apt  to  occur  in 
pregnancy,  paraplegia  being  the  commonest ;  and,  in  a  large 
proportion  of  cases,  they  are  associated  with  albuminuria.  Deaf- 
ness, or  injury  to  other  special  nerves,  may  arise  in  the  same  way. 
As  in  the  case  of  the  retina,  the  cause  may  probably  be  either 
local  haemorrhages  or  inflammatory  deposits.  In  most  cases 
recovery  or  improvement  takes  place  after  delivery. 

The  more  chronic  form  of  Bright's  disease  does  not  so  irequently 
lead  to  eclampsia  as  the  recent  and  usually  unobserved  attack. 
Seyfert  records  that  out  of  over  70  cases  in  which  women  suffering 
from  Bright's  disease  became  pregnant,  only  2  had  convul- 
sions. Hofmeier  records  that  out  of  46  cases  of  the  more  chronic 
form  of  nephritis  in  pregnancy,  one-third  of  the  patients  had 
convulsions. 

The  fact  that  chronic  Bright's  disease  in  pregnancy,  as  a  rule, 
does  not  produce  convulsions  may  be  explained  by  two  considera- 
tions. First,  the  degree  of  albuminuria  is  not  a  measure  of  the 
impairment  of  the  excretory  power  of  the  kidney,  and  in  chronic 


472  The   Practice  of   Midwifery. 

nephritis  a  certain  compensatory  balance  of  excretory  power  may 
have  been  attained.  Secondly,-  in  chronic  disease,  the  nerve- 
centres  may  be  supposed  to  have  become,  in  some  measure,  tolerant 
of  the  influence  of  the  toxins  in  the  blood.  Thus  when,  after 
eclampsia  in  a  first  pregnancy,  albuminuria  recurs  in  subsequent 
pregnancies,  the  eclampsia  does  not  recur  in  more  than  3  per  cent, 
of  the  cases. 

It  cannot  be  a  correct  explanation  that  the  albuminuria  is 
the  consequence  of  the  convulsions.  For,  in  most  cases,  the 
albuminuria  certainly  precedes  in  point  of  time.  And,  again, 
albuminuria  is  not  usually  the  result  of  ordinary  epileptic  fits, 
nor  even  of  those  cases  somewhat  resembling  eclampsia,  in  which  a 
series  of  epileptiform  convulsions,  in  rapid  succession,  leads  to 
a  fatal  result.  The  venous  congestion  produced  by  the  convulsions 
must,  however,  tend  to  increase  the  embarrassment  of  the  kidneys. 

In  the  chronic  nephritis  of  pregnancy  there  is  a  great  tendency 
to  abortion,  which  appears  generally  the  result  of  the  prior  death 
of  the  foetus,  or  to  premature  labour  with  a  still-born  child.  In 
many  cases  this  is  associated  with  the  occurrence  of  haemorrhages 
into  the  placenta  or  between  the  membranes  and  the  uterine  wall 
and  the  formation  of  numerous  large  white  infarcts.  I  have 
known  cases  in  which  eclampsia  has  occurred  at  the  first  preg- 
nancy, the  albumen  has  disappeared  or  greatly  diminished  in 
the  intervals  of  pregnancy,  but  a  series  of  pregnancies  have 
followed,  each  terminated  by  the  death  and  subsequent  expulsion 
of  the  foetus,  the  albuminuria,  accompanied  by  affection  of  the  eyes, 
having  recurred  with  each  pregnancy.  The  only  explanation 
possible  appears  to  be  either  that  the  foetus  perishes  from  insuffi- 
cient nutrition,  or  that  it  is  directly  killed  by  a  poison  present  in 
the  blood.  The  frequent  death  of  a  child  in  eclampsia,  where  the 
nephritis  present  is  usually  a  recent  attack,  is  in  favour  of  the  latter 
explanation. 

Treatment. — Very  slight  traces  of  albumen,  in  the  absence  of  any 
symptoms,  appear  to  be  of  little  significance,  especially  if  observed 
only  in  the  ninth  month,  or  during  or  just  after  actual  labour.  If, 
however,  the  proportion  of  albumen  is  considerable,  if  casts  are 
present,  or  if  there  is  general  oedema  or  other  constitutional 
symptoms,  treatment  is  called  for.  The  bowels  should  be  kept 
acting  freely,  both  with  a  view  to  keeping  down  arterial  tension, 
and  with  the  hope  of  carrying  off  some  waste  products  by  that 
channel.  The  kidneys  should  also  be  flushed  as  much  as  possible, 
to  prevent  impairment  of  excretory  power  by  the  choking  of  the 
tubes  with  epithelium.     The  best  diuretic  for  this  purpose  is  water, 


Disorders  of   Pregnancy.  473 

but  salines,  such  as  acetate  of  potash,  may  also  be  given.  In  recent 
and  acute  attacks  of  nephritis  advantage  has  been  derived  from  a  diet 
which  gives  the  kidney  as  little  work  as  possible  in  excreting 
nitrogenous  material.  This  indication  is  best  fulfilled  by  a  diet 
consisting  of  milk,  not  more  than  three  pints  in  the  day,  and 
starchy  material,  such  as  cornflour,  sago,  arrowroot,  etc.,  alone. 
The  patient  should  also  be  kept  in  bed,  both  for  the  avoidance  of 
chills,  and  for  the  effect  of  rest  in  diminishing  waste  products. 
In  chronic  cases,  according  to  the  modern  view,  it  is  better  not  to 
restrict  the  diet  too  much,  but  to  give  a  fair  amount  of  meat.  It 
seems  desirable,  however,  to  be  sparing  in  the  use  of  beef-tea  or 
meat  extracts.  Iron  should  be  given  in  the  more  chronic  cases 
when  there  is  anaemia.  Turkish  baths  may  be  used  to  stimulate 
the  action  of  the  skin.  When  albuminuria  comes  on  first  in  the 
later  months  in  a  primipara,  especially  if  urine  is  scanty,  albumen 
copious,  and  there  is  headache  or  affection  of  vision,  watch  must 
be  kept  for  the  outbreak  of  convulsions,  and  the  eyes  carefully 
examined  with  the  ophthalmoscope. 

Full  doses  of  bromide  of  potassium  may  be  given  as  a 
prophylactic,  and  chloral  may  be  added  if  premonitory  signs  are 
very  marked. 

For  cases  in  which  the  albuminuria  ap]3ears  to  be  due  to  the 
toxaemia  of  pregnancy,  and  not  chronic  Bright' s  disease,  treatment 
by  thyroid  extract  has  been  suggested  by  Nicholson,^  on  the  theory 
that  the  toxaemia  is  due  to  defective  metabolism,  and  that  the 
thyroid  extract  stimulates  metabolism.  At  any  rate,  the  thyroid 
treatment  tends  to  lower  arterial  pressure,  which  is  generally  ex- 
cessive in  albuminuria.  It  is  advisable  to  watch  daily  the  amount 
of  urine  secreted,  and  the  amount  of  urea,  especially  in  primiparae, 
and  when  the  albuminuria  is  attributed  to  the  toxaemia  of 
pregnancy. 

If  there  is  much  oedema  towards  the  end  of  pregnancy,  or  if  the 
proportion  of  albumen  is  large,  and  increases  notwithstanding 
treatment,  premature  labour  should  be  induced.  This  is  especially 
desirable  in  the  case  of  a  primipara,  and  still  more  if  there  are 
premonitory  symptoms  of  eclampsia,  such  as  headache  or  vomit- 
ing ;  if  albuminuric  retinitis  is  present ;  or  if  the  urine  is  scanty, 
or  the  elimination  of  urea  very  defective.  There  is  a  better  chance 
of  escaping  eclampsia  if  labour  is  brought  on  than  if  the  kidney 
disease  is  left  to  become  aggravated.  It  is  justifiable  even  to  induce 
abortion,  after   a   consultation,  if   grave   symptoms   are   present, 

1  Jouni.  of  Obst.  and  Gyri.  Brit.  Emp.,  July,  1902,  Vol.  II.,  p.  40. 


474  The   Practice  of   Midwifery. 

especially  serious  damage  to  the  retina,  or  paralysis,  or  a  threaten- 
ing of  eclampsia. 

Eclampsia. — Puerperal  convulsions,  or  eclampsia,  are  to  be 
distinguished  from  hysterical  convulsions,  and  from  convulsions 
set  up  by  lesions  of  the  brain  on  a  large  scale,  such  as  cerebral 
ha;morrhage.  The  disease  is  also  distinct  from  true  epileptic  fits, 
occurring  casually  in  pregnancy,  labour,  or  the  puerperal  state. 
The  epileptic  tendenc}'-,  however,  appears  sometimes  to  predispose 
to  actual  eclampsia. 

Clinical  History  and  Symjjtoms. — Sometimes  the  attack  comes  on 
without  any  premonitory  signs  having  been  observed,  the  patient 
having  been  about,  and  apparently  in  perfect  health.  More 
frequently  there  are  premonitory  signs,  especially  severe  headache, 
lasting  for  at  any  rate  some  hours,  and  sometimes  accompanied  by 
flashes  of  light,  or  other  affection  of  the  eyes.  Other  premonitory 
signs  sometimes  observed  are  nausea  and  vomiting,  severe  epigastric 
pain,  vertigo,  and  dimness  of  sight.  Sometimes  not  only  oedema  of 
the  lower  parts,  but  some  puftiness  of  the  face,  has  been  noticed  for 
a  few  days  or  for  a  week  or  two.  Marked  cedema  of  the  vulva  is 
generally  a  sign  of  nephritis.  The  onset  of  the  convulsions  may 
occur  either  during  pregnancy,  sometimes  as  early  as  the  sixteenth 
week,  but  generally  in  the  eighth  or  ninth  month,  during  labour, 
or  after  delivery. 

The  individual  convulsion  resembles  an  epileptic  convulsion, 
except  that  the  epileptic  cry  never  occurs.  Sometimes  a  definite 
tonic  stage  is  observed,  lasting  not  more  than  a  few  seconds.  The 
face  turns  suddenly  pale,  the  features  are  drawn  and  rigid,  the 
head  generally  drawn  to  one  side,  the  eyes  turned  up  showing  the 
whites,  the  muscles  rigid,  the  thumbs  turned  into  the  palms  of 
the  hands,  respiration  arrested.  Then  twitching  begins  at  the 
face  and  eyes,  and  extends  to  more  violent  jerking  movements  of 
the  head  and  neck,  and  of  tlie  limbs.  The  face  becomes  livid  and 
horribly  distorted,  the  veins  distended  from  interference  with 
respiration,  the  tongue  is  protruded  and  often  bitten,  the  breath 
escapes  with  a  hissing  sound,  and  is  accompanied  with  foam 
from  the  mouth.  At  this  stage  the  arteries  may  be  seen 
beating  violently,  the  passage  of  blood  through  the  lungs  being 
obstructed. 

In  other  cases  no  clear  distinction  between  tonic  and  clonic  stage 
can  be  made  out,  especially  when  the  fits  succeed  each  other  in 
quick  succession.  The  fits  begin  with  twitching  of  the  face  and 
eyeballs,  and  tonic  and  clonic  spasms  of  the  muscles  of  the  limbs 


Disorders  of   Pregnancy.  475 

seem  to  alternate.  In  the  tonic  spasms,  the  back  may  be  arched, 
as  in  opisthotonos. 

During  the  convulsions  there  is  complete  insensibility,  and  the 
pupils  do  not  act  to  light.  Urine  and  faeces  may  be  passed.  The 
clonic  stage  of  convulsion  may  last  from  half  a  minute  to  two 
minutes,  most  frequently  not  longer  than  one  minute. 

The  convulsion  is  followed,  for  a  short  time,  by  a  partial  degree 
of  coma,  with  stertorous  breathing.  After  a  first  attack,  conscious- 
ness is  soon  recovered,  but  the  patient  is  more  or  less  confused, 
having  no  remembrance  of  what  has  occurred,  and  sometimes  falls 
into  a  heavy  sleep.  The  special  character  of  the  convulsions  of 
eclampsia  is  that  they  recur.  In  mild  cases  there  may  be  only  a 
few  fits  at  long  intervals,  and  consciousness  may  always  return 
in  the  intervals.  In  severe  cases  the  convulsions  recur  with 
increasing  frequency,  and  in  some  instances  more  than  100  have 
occurred.  Sometimes  they  follow  in  such  quick  succession  as  to 
appear  almost  continuous.  When  several  convulsions  have 
occurred  at  short  intervals,  coma,  more  or  less  complete,  persists 
in  the  intervals.  Breathing  is  stertorous,  the  face  congested  and 
swollen,  the  tongue  often  swollen  and  bleeding.  The  patient  is 
generally  unconscious,  unable  to  understand  when  spoken  to,  or 
to  answer,  and  remembers  nothing  afterwards  of  her  condition. 
Keflex  sensibility,  however,  is  shown  if  she  is  touched,  or  when 
labour  pains  occur.  During  the  intervals  there  is  often  a 
certain  amount  of  muscular  rigidity  with  restlessness,  more 
marked  when  a  paroxysm  is  approaching.  The  sensibility  of 
the  pupils  to  light  is  diminished.  They  may  be  dilated  or  con- 
tracted, but  generally  are  contracted  shortly  before  and  during  a 
paroxysm. 

Convulsions  may  be  induced  by  external  stimuli,  especially  by 
vaginal  examinations.  Frequently  they  are  excited  by  a  labour 
pain.  The  pain  is  first  manifested  by  the  groaning  restlessness, 
and  bearing  down  of  the  patient,  the  uterus  may  be  felt  to  harden, 
and  then  the  convulsion  comes  on.  The  converse  relation  may  also 
exist,  and  the  paroxysm  may  induce  a  prolonged  tetanic  con- 
traction of  the  uterus,  lasting  several  minutes  longer  than  an 
ordinary  labour  pain.^  This  may  be  one  cause  of  the  frequent 
death  of  the  foetus,  by  arresting  or  greatly  diminishing  the  circula- 
tion through  the  placenta.  If  the  eclamptic  attack  comes  on 
during  pregnancy,  it  has  a  strong  tendency  to  cause  expulsion  of 

^  "  On  the  liehaviour  of  the  Uterus  in  Puerperal  Eclampsia,"  by  Dr.  Braxton  Hicks, 
Trans.  Obst.  Hoc.  London,  188.'5,  Vol.  XXV.,  p.  118.  Spiegelberg,  however,  states  it  as 
his  experience  that  the  uterus  is  never  observed  to  take  part  in  the  paroxysm. 


47^  The   Practice  of   Midwifery. 

the  foetus.  If  the  attack  is  sufficiently  severe  and  prolonged,  labour 
is  sure  to  come  on  sooner  or  later.  If  the  convulsions  come  on 
during  labour,  the  pains  of  the  second  stage  generally  progress 
with  vigour,  and  sometimes  the  child  is  rapidly  expelled.  This 
tendency  may  be  due  in  part  to  the  asphyxia  produced  by  the  con- 
vulsions, for  asphyxia  is  well  known  to  cause  the  uterus  to  expel  its 
contents.  Frequently  the  child  is  still-born.  Among  the  causes 
tending  to  its  death  are  the  interference  with  the  mother's  respira- 
tion, and  the  prolonged  tetanic  contractions  of  the  uterus,  when 
these  occur.  But  in  some  instances  of  mild  eclampsia  during 
pregnancy,  which  passed  off  without  bringing  on  labour,  but  were 
associated  with  copious  albumen  in  the  urine,  I  have  found  that 
the  child  died  at  the  time  of  the  convulsions,  but  was  expelled 
only  after  some  days  and  weeks.  This  is  evidence  in  favour  of  the 
view  that,  as  in  the  case  of  the  nephritis  of  pregnancy  without 
eclampsia,  a  poison  circulating  in  the  mother's  blood  has  an 
injurious  effect  upon  the  foetus. 

From  the  effect  of  repeated  convulsions,  the  pulse  becomes  rapid 
and  sometimes  small.  The  rate  may  rise  as  high  as  from  120  to 
140.  From  sphygmographic  tracings  taken  during  the  eclamptic 
state,  I  have  found  that  the  pulse  is  not  a  dicrotic  pulse  of  low 
tension,  like  the  ordinary  rapid  pulse  of  fever,  but  one  of  abnor- 
mally high  tension,  like  that  observed  in  Bright's  disease.  The 
temperature  also  rises  in  a  marked  degree  from  the  effect  of  the 
convulsions.  In  cases  not  actively  treated,  when  many  paroxysms 
occur  at  short  intervals,  it  may  rise  to  a  very  unusual  height,  such 
as  108°  or  109°.-^  Any  very  considerable  rise  of  temperature 
indicates  great  danger.  The  use  of  chloroform,  of  morphia,  or  of 
venesection,  however,  appears  to  interfere  with  the  rise  of  tem- 
perature. If  the  convulsions  are  arrested,  or  occur  at  longer 
intervals,  the  temperature  falls  again  even  though  the  coma  con- 
tinues. This  rise  of  temperature  is  contrasted  with  the  state  of 
things  in  ordinary  cases  of  urtemia  without  convulsions,  for  then 
the  temperature  tends  to  become  sub-normal.  A  similar  rise  of 
temperature  takes  place  when  a  fatal  result  follows,  in  either  sex, 
from  a  series  of  epileptiform  convulsions,  much  resembling 
eclampsia,  but  apart  from  pregnancy,  and  not  associated  with  any 
albuminuria  or  nephritis.  This  effect  on  temperature  appears  to 
be  evidence  that  the  comatose  state  of  the  eclamptic  patient 
indicates  actual  injury  to  the  nerve-centres  caused  by  the  eclamptic 
explosions,   an  injury  which  is  apt  to  lead   on  to   a  fatal  result- 

1  See  cases  recorded  by  Bourneville,  Etudes  Cliniques  et  Thermom^triques  sur  les 
Maladies  du  Systeme  Nerveux,  and  by  the  author,  Brit.  Med.  Journ.,  May  22,  1875. 


Disorders  of   Pregnancy.  477 

Pyrexia  also  occurs  apart  from  a  rapid  succession  of  convulsions, 
or  at  a  later  stage,  and  then  probably  implies  the  presence  of  some 
septic  element. 

Causation  and  Pathological  Anatomy. — Eclampsia  is  not  of  very 
common  occurrence.  Its  frequency,  however,  aj)pears  to  vary  in 
different  countries  and  at  different  times  and  places,  as  does  that  of 
puerperal  septicaemia  (see  Chapter  XXXIX.).  According  to 
Cassamayor,  in  Tarnier's  clinic  in  Paris  there  was  1  case  of 
eclampsia  to  every  47  labours  in  1872,  as  compared  with  1  to  730 
in  1882,  and  1  to  130  in  1891.  In  the  Guy's  Hospital  Charity  it 
occurred  once  in  842  deliveries,  and  fatal  cases  amounted 
to  1  in  3,368  deliveries.  In  New  York  City,  from  1867  to 
1875,  fatal  cases  amounted  to  1  in  about  700  deliveries. ■*■ 
In  the  thirteen  years  1892 — 1905  there  were  70  cases  of 
eclampsia  in  47,924  deliveries  at  the  Ptotunda  Hospital,  or  1  in 
694.^  The  general  estimate  for  Europe  is  about  1  case  in  600 
deliveries.  A  marked  circumstance  in  relation  to  the  causation  is 
the  special  liability  of  primiparge  to  the  disease.  In  the  Guy's 
Charity  60  per  cent,  of  the  cases  were  in  primiparse.  Other 
statistics  give  a  proportion  of  from  70  to  85  per  cent.  Multiple 
pregnancies  undoubtedly  appear  to  be  a  predisposing  cause,  and 
eclampsia  has  been  met  with  in  six  cases  of  hydatidiform  mole, 
where  no  foetus  was  present. 

Urine. — In  the  great  majority  of  the  cases  the  urine  is  found  to 
be  albuminous.  The  proportion  of  albumen  is  usually  large. 
Often  it  occupies  a  third  or  a  quarter  of  the  bulk  of  the  urine 
after  settling,  and  sometimes  the  urine  becomes  nearly  solid  on 
heating.  The  urine  is  not  only  albuminous,  but  frequently  also 
scanty,  and  sometimes  almost  suppressed.  Often  it  is  turbid  and 
smoky-looking  from  containing  blood.  Sometimes  the  quantity  of 
blood  is  sufficient  to  colour  it  red.  Pienal  epithelium  can  generally 
be  detected  by  the  microscope,  and  not  uncommonly  hyaline, 
granular,  and  fatty  casts.  It  has  been  found  by  Herman  that  in 
eclampsia  there  is  a  marked  diminution  in  the  quantity  of  urea 
excreted.  Helonin^  has  studied  the  relation  between  the  total 
nitrogen  of  the  urine  and  the  amount  eliminated  as  urea  in  the 
albuminuria  of  pregnancy  and  eclampsia.  He  concludes  that  in 
normal  urine  from  80  to  90  per  cent,  is  so  eliminated,  but  in  these 
diseased  conditions  a  much  smaller  proportion.     At  the  same  time 


'  Lusk,  Science  and  Art  of  Midwifeiy,  p.  526. 

2  De  la  Haipc,  Journ.  Oljst.  and  Gyn.  Brit.  Emp.,  lilOfJ,  Vol.  IX.,  p.  102. 
"  "  Contribution    a    I'Etude    du    Diagnostic  de    I'Hepato-toxhemie    Gravidique," 
Th^se,  Paris,  1899. 


478  The   Practice  of   Midwifery. 

it  must  be  remembered  that  the  nitrogenous  intake  in  these  patients 
is  often  very  small. 

The  quantity  of  urea  increases  again  in  patients  who  recover,  but 
not  in  cases  which  end  fatally.  There  is  thus  evidence  of  retention 
of  products  which  the  kidneys  should  secrete.  It  does  not  follow 
that  the  urea  itself  causes  the  convulsions ;  but  it  is  more  likely  to 
be  some  substance,  a  product  of  the  disintegration  of  protein,  which 
occurs  in  much  smaller  quantity,  but  is  more  poisonous.  If  the 
patient  recovers,  the  quantity  of  albumen  generally  rapidly  lessens 
after  delivery,  and  it  may  have  entirely  vanished  in  two  or  three 
days.  Usually,  however,  it  does  not  entirely  disappear  for  some 
weeks.  In  some  cases  a  small  proportion  of  albumen  remains  for 
many  months  afterwards,  but  yet  eventually  disappears,  and  does 
not  necessarily  recur  in  future  pregnancies.  In  other  cases  the 
albuminuria  remains  permanent.  Of  77  cases  investigated  by 
Koblanck,  in  5,  or  6*5  per  cent.,  chronic  nephritis  developed. 

In  general,  therefore,  it  may  be  said  that  the  albuminuria  is  not 
a  passive  transudation,  but  an  evidence  of  nephritis. 

Some  authorities  have  considered  that  the  importance  of 
albuminuria  in  connection  with  eclampsia  has  been  overrated,  and 
that  urgemic  eclampsia  is  only  one  out  of  several  common  varieties. 
Therefore,  since  the  albuminuria  was  first  discovered  in  the  Guy's 
Charity,  it  may  be  of  interest  to  record  that  out  of  all  cases  in  that 
charity  during  the  forty  years  up  to  1875  in  which  the  urine  was 
examined,  it  was  free  from  albumen  throughout  in  only  two.  In 
one  of  these  the  convulsions  were  produced  by  arachnitis,  as  verified 
by  an  autopsy;  in  the  other  they  followed  severe  post-partum 
haemorrhage,  in  a  girl  who  had  been  seduced.  The  total  number  of 
cases  in  which  the  presence  of  albuminuria  is  recorded  is  41, 
and  there  were  several  others  in  which  the  urine  was  suppressed, 
general  oedema  was  present,  and  there  was  no  doubt  of  the 
existence  of  nephritis. 

The  association  with  albuminuria  is  thus  so  general  as  to  prove 
absolutely  that  a  causal  relation  exists.  Either,  therefore,  the 
eclampsia  results  from  the  nephritis,  or  the  albuminuria  from  the 
eclampsia,  or  both  are  the  result  of  a  common  cause. 

An  important  point  in  connection  with  the  quantitative  analysis  of 
the  urine  is  the  estimate  of  the  total  quantity  of  nitrogen  excreted, 
normally  amounting  to  about  15*8  grammes,  of  which  the  urea 
accounts  for  87'7,  and  the  ammonia  for  3"3  per  cent.  In  eclampsia 
a  much  higher  proportion  is  excreted  in  the  form  of  ammonia  salts, 
while  the  proportion  excreted  as  urea  is  markedly  diminished. 
Besides  the  nitrogen  excreted  in  the  form  of  urea,  ammonia,  uric 


Disorders  of   Pregnancy.  479 

acid,  and  creatinine,  there  is  a  certain  amount  present  chiefly  in 
the  form  of  amino-acids,  the  so-called  undetermined  nitrogen,  and 
the  amount  of  this,  too,  in  cases  of  eclampsia  has  been  shown  by 
Ewing  and  Wolf  ^  to  bear  a  higher  proportion  than  the  normal  to 
the  total  quantity  excreted. 

It  is  very  important  to  remember,  in  drawing  any  clinical 
conclusion  from  the  analysis  of  the  urine,  that  the  highest  ammonia 
coefficient  is  seen  in  cases  of  prolonged  fasting,  and  that  a  high 
ammonia  coefficient  may  have  no  pathological  significance  at  all 
if  the  nitrogen  intake  is  low. 

ZweifeP  puts  forward  the  view  that  the  increased  excretion  of 
ammonia  is  due  to  increased  acidity  of  the  blood,  and  ascribes  it 
to  the  presence  of  lactic  acid,  which  he  regards  as  a  disintegration 
product  of  protein.  Further  investigations,  however,  lend  no 
support  to  his  view  that  lactic  acid  is  the  cause  of  eclamptic  con- 
vulsions ;  indeed,  they  tend  rather  to  show  that  it  is  either  the 
result  of  the  excessive  muscular  contractions  or  of  a  failure  of  the 
liver  to  convert  ammonia  into  urea. 

Chemical  analyses  of  the  blood,  urine,  liver,  and  placenta  have 
shown  that  these  organs  contain  in  eclampsia  considerable  quantities 
of  the  products  of  protein  disintegration,  and  it  seems  probable 
that  in  this  disease  a  process  of  autolysis  of  the  tissues  of  these 
organs  takes  place  to  a  considerable  degree. 

Examination  of  the  blood  has  shown  that  its  alkalinity  is 
sometimes  diminished,  and  that  there  is  a  marked  increase  in 
the  amount  of  fibrinogen  present,  and  a  great  increase  in  the 
number  of  white  corpuscles. 

Pathological  Anatomy :  Kidney. — In  fatal  cases  of  eclampsia, 
generally  only  an  early  stage  of  tubal  nephritis  has  been  found, 
and  some  observers  have  not  detected  anything  more  than  con- 
gestion, Schmorl,^  however,  has  shown  that  renal  changes  are 
present  in  99  per  cent,  of  all  cases.  His  investigations  confirm 
those  of  other  observers,  and  have  demonstrated  that  the  change, 
affecting  chiefly  the  epithelium  of  the  convoluted  tubules,  is  of  a 
degenerative  character,  and  consists  in  cloudy  swelling,  fatty 
degeneration,  and  coagulation  necrosis  of  the  protoplasm  of  the 
cells.  The  glomeruli,  as  a  rule,  are  unaffected,  though  fibrinous 
thrombi  are  present  in  their  capillaries.  The  kidneys  are  att'ected 
unequally,  and  healthy  and  diseased  patches  may  be  seen  lying  side 

1  Ewing  and  Wolf,  Amer.  Journ.  Obstet.,  1907,  Vol.  LV..  No.  3,  p.  289. 

2  Zweifel,  Zentralbl.  f.  GynJik.,  1909,  No.  26,  p.  897  ;  Aroh.  f.  Gynak.,  1904,  Bd.  72, 
p.  r,72;  Dieiist,  Zentralbl.  f.  Gyniik.,  1905,  No.  12,  p.  .353;  Arch.  f.  Gyniik.,  1908, 
Bd.  HC,  p.  314. 

»  Schmorl,  Zentralbl.  f.  Gynak.,  190.5,  No.  .5,  p.  129. 


480  The  Practice  of   Midwifery. 

by  side  (see  Fig.  i568).  It  is  interesting  to  note  that  Angus 
Macdonald,  arguing  from  the  autopsies  of  two  cases,  considered  the 
renal  condition  to  be  a  degeneration  rather  than  an  inflammation, 
the  epitheHal  cells  in  some  tubes  being  converted  into  a  colloid 
material,  which  plugs  both  these  and  other  tubes. ^ 

Liver. — Of  recent  years  much  attention  has  been  directed  to 
lesions  of  the  liver,  of  the  nature  of  a  thrombotic  hepatitis,  with 
degeneration  of  the  liver  cells.  By  some,  especially  by  French 
authorities,  these  are  considered  to  be  primary,  and  to  be  of  more 
importance  than  the  renal  changes.  They  thus  regard  the  disease 
as  a  toxaemia  of  hepatic  origin.  In  a  small  proportion  of  cases 
there  is  jaundice  as  a  complication,  and  these  cases  are  generally 
fatal.  Schmorl  found  the  liver  affected  in  71  of  his  73  cases. 
The  changes  have  been  studied  in  great  detail  by  Konstantinowitsch,  ^ 
who  has  shown  that  the  earliest  change  is  degeneration  of  the  liver 
cells  at  the  periphery  of  the  lobule,  followed  by  thrombosis  of  the 
capillaries  secondary  to  changes  in  their  endothelium  and 
haemorrhages  into  the  liver  substance.  These  changes  are  followed 
by  necrosis  of  the  liver  cells  in  the  areas  of  thrombosis  and  this 
in  its  turn  by  further  thrombosis  in  the  interlobular  vessels  and 
the  formation  of  still  larger  areas  of  necrotic  liver  tissue.  He  lays 
considerable  stress  on  the  characteristic  primary  limitation  of  the 
change  to  the  periphery  of  the  lobules. 

Brain. — In  about  90  per  cent,  of  the  cases  thrombosis  of  the 
capillaries,  together  with  areas  of  necrosis  and  hsemorrhages, 
is  found  both  in  the  cortex  and  in  the  medulla. 

Heart. — In  the  same  way  in  about  60  per  cent,  of  the  cases 
degenerative  changes  in  the  muscle  fibres  occur,  together  with  areas 
of  necrosis  and  interstitial  haemorrhages. 

Placenta. — The  formation  of  white  infarcts  in  the  placenta  and 
their  frequency  in  cases  of  albuminuria  have  already  been  pointed 
out.  In  cases  of  eclampsia  other  changes  have  been  described, 
consisting  of  large  haemorrhages  and  marked  proliferation  and 
degeneration  of  the  syncytium. 

One  of  the  most  characteristic  features  of  cases  of  eclampsia  is 
the  occurrence  of  thrombi  in  the  capillary  vessels  of  almost  all  the 
organs  of  the  body. 

Causation. — A  consideration  of  the  chemical  and  pathological 
changes  described  in  the  urine,  the  blood,  and  the  organs,  shows 
that  the  most  characteristic  changes  met  with  in  eclampsia  are  as 
follows :  marked  degenerative  processes  in  the  cells  of  the  kidneys 

1  Obstet.  Journ.,  1878,  Vol.  VI. 

2  Ziegler's  Beitrage,  1907,  No,  40,  Hf  t.  3,  p.  483. 


Disorders  of   Pregnancy.  481 

and  the  liver,  together  with  evidence  of  a  disturbance  of  tissue  meta- 
bolism, the  accumulation  of  the  products  of  protein  disintegration  in 
the  tissues  and  in  the  urine,  and  changes  in  the  blood,  associated 
with  increased  coagulability  and  the  formation  of  numerous 
thrombi  throughout  the  body. 

Probably  the  most  important,  as  it  is  the  most  striking,  of  these 
changes,  is  the  evidence  of  the  presence  of  the  products  of  protein 
disintegration   in   the   urine   and  the   tissues.     Such  evidence  is 


I 

V 


X 


^ 


°  J 

Fig.  268. — Kidney  from  a  case  of  eclampsia,  showing  cloudy  swelling  and 
coagulation  necrosis  of  the  epitheliam  of  the  convoluted  tubules.  The 
glomeruli  are^unafEected. 

furnished  by  the  presence  of  abnormal  organic  and  inorganic  fatty 
acids  in  the  liver  and  the  urine,  and  the  presence  of  lactic  acid, 
together  with  the  large  proportion  of  undetermined  nitrogen  and  the 
large  ammonia  coefficient  found  in  the  urine  in  cases  of  eclampsia. 
The  most  probable  explanation  of  the  presence  of  these  substances 
is  that  they  are  the  results  of  the  autolysis  of  the  cells  of  various 
organs,  especially  those  of  the  liver,  and  that  the  result  of  these 
destructive  changes  is  the  saturation  of  the  tissues  of  the  body  with 
the  products  of  protein  disintegration,  leading  to  a  condition  of 
M.  31 


482 


The  Practice  of   Midwifery. 


toxaemia,  or  auto-intoxication,  which  is  the  essential  factor  in  the 
production  of  eclampsia. 

Since  autolysis,  due  as  it  is  to  the  action  of  the  intracellular 
ferments  upon  the  protoplasm  of  the  cell,  does  not  usually  occur  in 
living  tissues,  it  is  necessary,  if  we  are  to  accept  this  view  of  the 
causation  of  eclampsia,  to  find  some  primary  cause  to  explain  the 
occurrence  of  such  autolytic  changes. 


Fig.  269. — Liver  from  a  patient  dying  of  eclampsia,  showing  necrosis  of  the 
liver  cells  at  the  periphery  of  several  lobules,  with  thrombosis  of  the 
interlobular  vessels.  Complete  necrosis  of  the  whole  of  one  lobule  is 
also  shown  at  the  upper  left  hand  corner  of  the  figure. 

What  is  the  nature  and  what  is  the  origin  of  the  body  which 
initiates  the  series  of  changes  leading  to  the  profound  disturbance 
of  tissue  metabolism  and  the  marked  tissue  necrosis  so  characteristic 
of  eclampsia?  No  doubt  the  poison  which  causes  the  auto-intoxica- 
tion of  eclampsia  is  the  same  as  that  which  is  responsible  for  the 
so-called  toxaemia  of  jiregnancy.  At  one  time  it  was  supposed  to 
be  derived  from  the  foetus,  but  the  fact  that  eclampsia  may  occur 
without  the  presence  of  a  foetus  in  cases  of  hydatidiform  mole 
proves  this  theory  to  be  erroneous. 

The  possibility  of  a  foetal  origin  being  excluded,  it  was  natural 
that  the  placenta  should  be  regarded  as  a  possible  source  of  the 
poison,  and  this  view  was  greatly  encouraged  by  the  discovery  by 


Disorders  of  Pregnancy.  483 

Schmorl  of  the  presence  of  placental  cells  in  the  vessels  of  the 
lungs  in  nearly  all  cases  of  eclampsia.  They  have  since  been  shown 
to  occur  in  other  conditions  than  eclampsia,  and  indeed  in  normal 
pregnancy.  This  observation,  however,  may  be  said  to  have 
originated  the  placental  theory  of  eclampsia. 

Veit^  put  forward  the  view  that  these  placental  cells  were  toxic  to 
the  mother ;  and  that,  while  in  normal  circumstances  they  were 
rendered  harmless  by  the  action  of  certain  anti-bodies  which  he 
termed  syncytiolysins,  when  in  excess  they  produced  albuminuria 
and  eclampsia.  Ascoli  supported  the  same  theory,  but  thought 
that  the  anti-bodies  were  the  toxic  agents,  and  not  the  cells. 

Further  investigations  have  failed  to  confirm  the  results  obtained 
by  Veit  and  other  workers,  and  have  thrown  grave  doubts  upon  the 
whole  theory,  which  probably  is  erroneous. 

Experiments  carried  out  by  the  injection  of  placental  extracts 
into  animals  have  shown  that  such  substances  have  a  highly  toxic 
effect,  and  that  this  is  mainly  due  to  the  nucleo-proteid  they 
contain  causing  widespread  capillary  thrombosis.  The  importance 
of  this  observation  is  considerable  when  we  remember  what  a  large 
part  capillary  thrombosis  plays  in  the  pathology  of  eclampsia. 

The  placenta  has  further  been  shown  to  be  an  organ  very  rich  in 
ferments,  and  the  process  of  autolysis  takes  place  in  it  with  great 
activity  after  death.  Indeed,  some  observers  have  maintained  that 
autolysis  may  take  place  in  it  during  life,  that  in  eclampsia  there 
is  hyperactivity  of  the  placental  ferments,  and  that  the  passage  of 
these  ferments  and  the  products  of  the  autolysis  of  the  placental 
tissues  into  the  blood  may  be  the  primary  morbid  change  leading 
to  eclampsia. 

The  view  which  most  observers  hold  at  the  present  time  as  to  the 
nature  of  eclampsia  is  that  it  is  an  auto-intoxication  of  the  body  due 
to  the  presence  in  the  tissues  of  the  products  of  protein  disintegra- 
tion, and  that  the  production  of  these  toxic  substances  is  due  to 
a  special  activity  of  the  intracellular  ferments  leading  to  autolytic 
changes  in  various  organs.  Further  than  this,  the  placental  theory 
supposes  that  there  is  a  passage  of  ferments  and  products  of 
autolytic  changes  from  the  placenta  into  the  body  generally, 
resulting  in  a  widespread  thrombosis  and  the  increased  activity  of 
the  autolytic  ferments  of  other  organs  with  an  excessive  formation 
of  toxic  bodies,  and  the  condition  of  toxic  poisoning  characteristic 
of  ecbtmpsia. 

The  differences,  clinical  and  pathological,  which  exist  between 
the  various  diseases — acute  yellow  atrophy,  the  pernicious  vomiting 

1  Scholten  and  Volt,  Zentralbl.  f.  Gyruik.,  1902,  No.  7,  p.  J«!J;   i;»04,  No.  1,  p.  1. 

31—2 


484  The  Practice  of   Midwifery. 

01  pregnancy,  ursemia,  and  eclampsia — all  no  doubt  examples  of 
auto-intoxication,  may  well  be  explained  by  variations  in  the  nature 
and  chemical  composition  of  the  different  toxic  bodies  which  are  the 
essential  factors  in  their  causation,  while  the  part  played  by  the 
placenta  in  the  production  of  eclamptic  convulsions  may  be  a 
possible  explanation  of  the  differences  which  exist  between  this 
disease  and  ursemia. 

In  the  great  majority  of  cases,  the  presence  in  the  blood  of  these 
toxic  bodies,  which  are  retained  owing  to  impaired  excretory  powers 
in  the  kidneys,  is  the  essential  element  in  the  causation.^  It  is  not, 
however,  the  sole  cause,  but  with  it  are  combined  the  increased 
irritability  of  the  nerve  centres  in  pregnancy,  and  the  presence  of  a 
cause  of  reflex  irritation  in  the  pregnant  uterus,  and  often  in  actual 
labour  pains.  That  reflex  irritation  is  a  cause  actually  operating  is 
proved  by  the  fact  that  more  than  half  of  the  cases  commence 
during  actual  labour,  that  a  paroxysm  may  be  excited  by  vaginal 
examination  or  the  introduction  of  the  hand  to  operate,  and  that 
the  convulsions  frequently  subside  after  delivery.  The  combination 
of  the  effect  of  a  poison  in  the  blood  and  of  reflex  irritation  may  be 
illustrated  from  physiological  experiments.  It  is  possible  to  give 
such  a  dose  of  strychnia  to  a  frog  that  it  remains  free  from  convul- 
sions, and  recovers,  if  left  perfectly  quiet.  By  touching  it,  however, 
spasms  are  excited,  and  these,  if  repeated,  will  kill  the  frog.  It  is 
not,  therefore,  wonderful  that  in  pregnant  women  convulsions  may 
be  the  result  of  a  recent  acute  nephritis,  whereas  in  ordinary 
Bright's  disease  they  only  occur  in  a  late  stage  of  ursemia. 

The  immediate  mechanism  by  which  the  convulsions  are  pro- 
duced is  uncertain.  They  may  be  caused,  like  the  spasms  produced 
by  strychnia,  by  the  direct  action  of  the  poison  on  the  nerve-centres. 
Since  convulsions  sometimes  occur  in  animals  bled  to  death,  it  has 
been  supposed  by  some  that  the  immediate  antecedent  is  ansemia 
of  the  brain,  caused  by  spasm  of  the  arteries.  Another  theory  of 
the  production  of  cerebral  ansemia,  the  Traube-Eosenstein  theory, 
has  been  rather  widely  circulated.  It  was  suggested  by  Traube  for 
ordinary  uraemic  convulsions,  and  has  been  adapted  by  Eosenstein 
to  the  case  of  puerperal  eclampsia.     The  theory  is,  that  there  is 

1  Further  than  this,  Bradford's  experiments  have  shown  that  when  the  available 
kidney  substance  is  diminished  beyond  a  certain  amount,  roughly  speaking  one  quarter 
of  the  total  kidney  weight,  the  protein  tissues  undergo  rapid  disintegration  with  the 
formation  of  abnormal  quantities  of  extractives.  In  eclampsia  the  destruction  of  the 
kidney  substance  must  often  amount  to  a  considerable  portion  of  the  whole  kidney 
(Bradford,  Proc.  Roy.  Soc,  1892). 

For  an  excellent  review  of  recent  work  on  eclampsia,  with  a  full  bibliography,  to 
which  the  authors  desire  to  acknowledge  their  indebtedness,  see  Eardley  Holland, 
Journ.  Obst,  and  Gyn.  Brit.  Emp.,  1909,  Vol.  XVI.,  Nos.  4,  5,  6. 


Disorders  of   Pregnancy,  485 

excessive  arterial  pressure,  combined  with  watery  blood ;  that  this 
produces  transudation  from  the  vessels,  and  thence  cedema  of  the 
brain,  by  which  the  vessels  are  in  their  turn  compressed,  being 
enclosed  within  the  skull,  and  so  anaemia  of  the  brain  is  produced, 
and  consequent  convulsions.  If  this  theory  were  true,  since  the 
same  cause  of  oedema  would  operate  all  over  the  body,  the  tendency 
to  ursemic  or  puerperal  convulsions  ought  to  be  proportional  to  the 
tendency  to  general  oedema.  This  is  not  the  fact,  for  ordinary 
urgemic  convulsions  are  most  frequent  in  the  case  of  contracted 
granular  kidney,  when  there  is  little  or  no  general  oedema ;  and 
general  oedema  is  generally  not  very  marked  in  puerperal 
eclampsia. 

Diagnosis. — ^The  diagnosis  from  hysterical  ursemic  and  epileptic 
convulsions  generally  is  easy.  In  convulsions  set  up  by  some  gross 
cerebral  lesion,  such  as  cerebral  haemorrhage,  there  will  generally 
be  accompanying  paralysis,  such  as  hemiplegia,  and  the  coma  will 
come  on  more  suddenly. 

Prognosis. — The  prognosis  is  grave.  The  mortality  is  now 
reckoned  at  from  20  to  25  per  cent.,  and  it  was  greater  before  the 
introduction  of  the  treatment  by  inhalation  of  chloroform.  Herz- 
feld,  however,  recently  collected  463  cases  with  a  mortality  of  17 
per  cent.  Hirst^  records  86  cases  with  a  total  mortality  of  27'4  per 
cent.,  33"8  per  cent,  of  the  primiparae  and  14*25  per  cent,  of  the 
multiparae  dying. 

About  50  per  cent,  of  the  children  are  lost.  The  danger  is 
greater  the  earlier  the  convulsions  begin,  and  the  more  frequently 
they  occur,  although  recovery  has  been  recorded  after  the  occurrence 
of  over  200  fits.^  The  early  onset  of  coma,  the  presence  of  complete 
anuria,  and  a  continuous  high  temperature  are  signs  of  bad  prog- 
nostic omen. 

On  the  other  hand,  the  excretion  of  an  increasing  quantity  of  pale 
urine,  and  an  increase  in  the  percentage  of  urea  present  are  good 
signs. 

In  the  Guy's  Charity,  the  mortality  was  50  per  cent,  in  cases 
which  began  before  the  onset  of  labour,  25  per  cent,  in  those  which 
began  during  labour,  and  only  8  per  cent,  in  those  which  began 
after  delivery,  the  total  mortality  being  25  per  cent,  up  to  1875.  In 
the  ten  years  1875 — 1885,  however,  the  mortality  was  only  9  per 
cent.  Lohlein's  ^  statistics  give  a  mortality  of  40'5  per  cent,  out  of 
83   cases  which  began  before  the  onset  of  labour.     Death  most 

1  Hirst,  Therap.  Gaz.,  I'hiladelpliia,  April,  ]!)07,  p.  220. 

2  Engelmaiiii,  Zeiitralbl.  f.  Gyniik.,  1907,  No.  1 1 ,  p.  HOC. 
8  Zeitschr.  f.  Geburtsh.  u.  G yuaek.,  B.  4,  H.  2. 


486  ThePractice  of   Midwifery. 

frequently  results  from  the  coma,  with  exhaustion  ;  sometimes  it 
occurs  in  a  paroxysm.  There  is  also  a  predisposition  to  puerperal 
disorders,  such  as  septicaemia,  oedema  of  the  lungs,  pneumonia, 
puerperal  insanity,  and,  it  is  said,  to  post-partinn  haemorrhage. 

Treatment. — Prophylactic  treatment,  for  cases  in  which  albu- 
minuria has  been  discovered,  has  been  already  considered  under 
the  head  of  albuminuria.  When  one  or  more  convulsions  have 
occurred,  the  first  treatment  should  be  to  give  an  active  purgative. 
This  lowers  arterial  tension,  without  weakening  so  much  as  vene- 
section, it  may  possibly  carry  off  some  poisonous  material  from  the 
blood  through  the  bowel,  and  it  may  sometimes  remove  one  of  the 
sources  of  reflex  irritation  in  the  shape  of  an  accumulation  in 
the  bowels.  When  the  patient  is  conscious,  any  hydragogue 
purgative,  such  as  the  Pulvis  Jalapae  Co.,  may  be  used.  If  she  is 
comatose,  the  best  plan  is  to  jDlace  two  drops  of  croton  oil  at  the 
back  of  the  tongue,  or  the  stomacli  may  be  washed  out  and  one  or 
two  ounces  of  a  saturated  solution  of  magnesium  sulphate  intro- 
duced into  it.  The  chief  aim  in  the  treatment  of  these  cases  is  to 
arrest  the  convulsions,  to  eliminate  the  toxins  from  the  patient's 
body  as  completely  as  possible,  and,  as  a  further  measure  when 
necessary,  to  remove  the  probable  source  of  the  poison  and  an 
undoubted  cause  of  reflex  irritation  by  emptying  the  uterus. 

It  is  of  great  importance  to  check  or  limit  the  number  of  convul- 
sions, since  a  rapid  succession  of  them  generally  leads  to  a  fatal 
result.  The  most  effective  means  for  this  end  are  the  subcutaneous 
injection  of  morphia  and  the  administration  of  chloroform.  The 
morjDhia  must  be  given  in  full  doses.  Half  a  grain  may  be  injected  at 
first,  and  afterwards  one-third  of  a  grain  at  about  six  hours  interval. 
The  effect  of  the  drug  on  the  pupil  must  be  watched,  and  not  more 
than  two  grains  given  in  the  twenty-four  hours,  although  as  much  as 
12  grains  have  been  administered  in  four  days.  De  la  Harpe^  records 
71  cases  treated  at  the  Kotunda  Hospital  by  the  administration  of 
morphia  with  12  deaths,  or  a  mortality  of  16'9  per  .cent.  In 
cases  where  the  patient  is  deeply  comatose  morphia  must  be  given 
with  caution,  and  some  authorities  maintain  that  it  is  best  given 
by  the  rectum  in  the  form  of  suppositories. 

Chloroform  should  be  administered  until  the  morphia  has  had 
time  to  act,  or  if  it  fails  to  check  the  convulsions,  or  if  any  obstetric 
interference  is  called  for.  It  has  a  great  influence  in  preventing 
the  recurrence  of  the  fits,  and  it  allows  any  necessary  manipulation 
to  be  carried  out  without  the  probability  of  exciting  a  paroxysm. 
When  the   administration  is  commenced   during   the   consecutive 

1  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  1906,  Vol.  IX.,  No.  2,  p.  102. 


Disorders  of   Pregnancy.  4S7 

coma,  this  condition  is  generally  ameliorated.  The  arterial  tension 
is  lowered,  and  the  pulse  at  the  same  time  becomes  slower,  restless- 
ness is  diminished,  contraction  of  the  pupils  passes  off,  and  usually 
the  breathing  becomes  less  stertorous,  and  the  venous  congestion 
of  the  face  diminishes.  Chloroform  should  always  be  administered 
when  fits  continue  to  recur  frequently,  or  when  there  is  material 
elevation  of  temperature.  At  first  the  patient  may  be  brought 
pretty  fully  under  the  influence  of  the  drug,  but  afterwards  it  may 
be  given  only  from  time  to  time,  and  in  partial  degree.  Any 
premonitory  signs  of  a  paroxysm,  such  as  increased  muscular  rest- 
lessness, more  rapid  breathing,  or  contraction  of  the  pupils,  are 
indications  for  giving  more  of  the  chloroform,  and  so,  a  fortiori,  is 
the  recurrence  of  a  fit.  When  chloroform  is  given  judiciously,  in 
this  partial  degree,  the  administration  may  be  continued  for  hours 
together  without  danger.  Next  to  morphia  and  chloroform,  the 
most  valuable  drugs  are  chloral  and  bromide  of  potassium.  These 
are  most  suitable  for  mild  cases,  such  as  those  which  commence 
after  delivery  usually  prove  to  be,  and  for  those  in  which  it  is 
either  impossible  to  carry  out  the  prolonged  administration  of 
chloroform,  or  it  is  thought  unsafe  to  continue  it  longer.  Thirty 
grains  of  chloral,  with  the  same  quantity  of  bromide  of  potassium, 
may  be  given  either  by  mouth  or  by  enema  in  one  or  two  doses. 
Some  American  authorities  praise  tincture  of  veratrum  viride, 
given  subcutaneously  in  doses  of  10  to  20  minims,  so  as  to  keep  the 
pulse  rate  down  to  60  per  minute  and  reduce  its  tension.  Mirto^ 
has  recorded  a  series  of  61  cases  treated  with  veratrum  viride  with 
5  deaths,  or  a  total  mortality  of  8*04  per  cent. 

Treatment  by  thyroid  extract  has  been  suggested,^  and  favourable 
results  reported.  The  evidence  does  not,  however,  appear  con- 
clusive at  present,  since  the  morphia  treatment  was  employed  at 
the  same  time.  It  is  advised  to  give  five-grain  tabloids  every  three 
or  four  hours,  until  symptoms  of  thyroidism  appear  in  the  form  of 
flushing  of  skin,  perspiration,  accelerated  pulse,  and  increased 
secretion  of  urine.  In  urgent  cases,  when  coma  is  present,  the 
drug  may  be  given  per  rectum  or  even  subcutaneously. 

While  an  attempt  is  being  made  to  control  the  convulsions  by 
one  or  other  of  the  means  described,  further  treatment  should  be 
carried  out  with  a  view  to  eliminating  or  at  any  rate  diluting  the 
toxic  bodies  which  are  present  in  the  blood  and  tissues  of  the 
eclamptic  patient.     The  most  rapid  and  effectual  method  of  doing 

^  Anniili  di  Ostet.  c.  (linecol.,  December,  1905. 

2  Nichoi.Hoii,  " 'I'ljyroid  Extract  in  EclarnpHia,"  Journ.  of  Obst.  and  Gyn.,  July, 
iy02,  Vol.  il.,  p.  40. 


488  The  Practice  of   Midwifery. 

this  is  undoubtedly  to  practise  venesection  followed  by  the  intro- 
duction of  normal  saline  solution  either  into  a  vein,  by  the  rectum, 
or  subcutaneously.  This  mode  of  treatment  is  especially  applicable 
to  plethoric  patients.  At  the  same  time  that  saline  transfusion  is 
being  practised  hot  air  or  hot  baths  should  be  given  in  order  to 
promote  the  action  of  the  skin.  Hot  air  baths  should,  however, 
not  be  given  without  the  simultaneous  administration  of  consider- 
able quantities  of  fluid  by  the  mouth  or  by  transfusion,  since  it  is 
possible  that  the  free  elimination  of  fluid  through  the  skin  may 
lead  to  a  concentration  of  the  poison  unless  it  is  replaced  by  the 
free  administration  of  fluids  by  the  mouth  or  subcutaneously.^  If 
free  purgation  can  be  set  up  it  is  of  advantage,  but  often  purgatives 
administered  by  the  mouth  are  not  absorbed,  and  reliance  must  be 
placed  upon  large  enemata. 

The  large  bowel  should  be  well  flushed  out  with  copious  enemata  of 
soap  and  water  until  faecal  matter  is  no  longer  passed,  and  it  is  a  good 
plan  to  leave  about  one  pint  of  normal  saline  solution  in  the  bowel. 
In  cases  where  the  secretion  of  urine  is  scanty,  the  application  of 
large  fomentations  or  dry  cupping  over  the  kidney  region  may  be 
tried. 

When  the  secretion  of  urine  is  exceedingly  scanty,  and  other 
means,  including  the  emptying  of  the  uterus,  have  failed  to  arrest 
the  convulsions,  and  especially  in  cases  occurring  after  delivery, 
the  operation  of  decapsulation  of  the  kidneys  has  been  suggested 
and  practised  with  varying  success.^  The  object  of  the  operation  is 
to  relieve  the  increased  tension  in  the  kidneys  which  is  supposed  to 
be  present  and  to  interfere  with  their  functions.  The  mortality  of 
the  operation  is  high,  37  per  cent,  or  more,^  and  further  experience 
is  required  to  determine  whether  this  procedure  is  likely  to  have 
any  permanent  place  in  obstetric  practice. 

In  cases  where  the  fits  continue  in  spite  of  treatment  and  labour 
has  not  commenced,  the  great  question  is  whether  to  induce  labour 
or  not.  In  mild  cases,  in  which  only  one  or  two  or  three  fits  occur 
at  wide  intervals,  and  leave  no  notable  coma,  it  may  be  sufiicient  to 
give  purgatives,  chloral,  and  bromide  of  potassium,  and  put  the 
patient  on  a  milk  diet,  watching  carefully  the  proportion  of  albumen 
in  the  urine.  But  if  the  case  is  at  all  severe — and  it  is  to  be 
remembered  that  cases  commencing  before  labour  are  much  the 
most  dangerous  of  all — it  appears  advisable  to  empty  the  uterus, 
provided  that  no  means  which  increase  the  patient's  danger  are 

1  Leopold,  Zentralbl.  f.  Gynak.,  1907,  No.  32,  p.  572. 

2  Gauss,  Zentralbl.  f.  Gynak.,  1907,  No.  19,  p.  521. 

8  Pfannenstiel,  Miinchener  Med.  VVochenschr.,  1908,  JSTo.  36,  p.  1903. 


Disorders   of   Pregnancy.  489 

employed  in  doing  so,  since,  in  the  majority  of  cases,  the  kidneys 
rapidly  improve  after  delivery.  Herman  has,  indeed,  adduced 
statistics  to  show  that  no  advantage  is  gained  by  doing  so  ;  but  those 
collected  by  Zweifel^  show  a  mortality  of  28*5  per  cent,  under 
expectant,  and  one  of  only  11*2  per  cent,  under  active  treatment. 
Indeed,  if  we  accept  the  view  that  the  primary  cause  of  eclampsia 
is  to  be  found  in  the  contents  of  the  uterus,  and  if  at  the  same  time 
we  admit  that  the  presence  of  the  fcetus  in  utero  undoubtedly  acts 
as  a  source  of  reflex  irritation,  then  the  emptying  of  the  uterus  when 
the  convulsions  cannot  be  controlled  by  other  means  seems  a  rational 
mode  of  treatment.  It  is,  at  any  rate,  a  method  of  treatment  which 
at  the  present  day  is  practised  by  many  obstetricians  of  note  whose 
views  must  carry  great  weight.^  Indeed,  Bumm  suggests  that  the 
rapid  delivery  of  every  patient  on  the  occurrence  of  the  first  fit  would 
be  followed  by  a  lowering  of  the  maternal  mortality  to  5  per  cent. 

The  first  principle  is  to  carry  out  no  manipulation  except  with  the 
aid  of  chloroform,  for  fear  of  setting  up  a  convulsion.  The  best 
mode  of  inducing  labour  is  to  puncture  the  membranes.  This  at 
once  takes  off  some  of  the  reflex  irritation  by  diminishing  the  tension 
of  the  uterus.  In  some  cases  I  have  found  this  suffice  to  stop  the  fits, 
while  labour  has  not  come  on  for  a  day  or  so.  If  the  fits  continue, 
and  labour  does  not  progress,  it  should  be  accelerated  by  dilatation 
of  the  cervix.  If  the  internal  os  is  expanded  and  the  cervical  canal 
obliterated,  the  external  os  may  be  rapidly  dilated,  either  digitally, 
if  it  is  yielding,  or  by  Bossi's  dilator  (see  Chapter  XXVII.),  the 
patient  being  placed  fully  under  the  influence  of  chloroform.  If 
the  cervical  canal  is  still  intact,  a  more  gradual  mode  of  dilatation  is 
generally  preferable,  to  avoid  the  risk  of  laceration,  and  that  of 
septic  infection  to  which  eclamptic  patients  are  specially  liable.  A 
Champetier  de  Eibes'  bag  (see  Chapter  XXVII.)  may  be  applied  ; 
and  if  satisfactory  pains  do  not  soon  come  on,  a  weight  may  be 
attached  to  the  bag  to  increase  its  dilating  power.  Meanwhile 
morj)hia  should  be  given,  or  the  partial  administration  of  chloroform 
should  be  continued. 

The  patient  being  already  in  labour,  the  general  principle  is  to 
accelerate  the  labour,  if  it  does  not  proceed  rapidly,  so  far  as  this 
can  be  done  without  any  violent  interference,  chloroform  being 
always  given  during  manipulations,  even  the  passing  of  a  catheter. 
The  second  stage  is  often  rapid  and  tumultuous,  but  the  first  stage 
is  apt  to  be  protracted.     If  the  labour  progresses  satisfactorily,  and 

1  "  Zur  Behandluiig  der  Eklampsie,"  Zentralbl.  f.  Gynak.,  1895. 

2  Buinm,  Miincherier  Med.  Wochciischr.,  11)03,  No.  21,  and  1907,  No.  47  ;  Liepmann, 
Miinchener  Med.  Wochenschr.,  1906,  No.  25. 


490  The  Practice  of   Midwifery. 

the  fits  are  controlled  by  treatment,  no  interference  with  it  is  needed. 
Otherwise  the  cervix  may  be  dilated,  as  already  described.  In 
urgent  cases  bipolar  version  may  be  performed  as  soon  as  the  os  will 
admit  two  fingers,  pro\dded  that  the  membranes  are  then  intact,  and 
delivery  accelerated,  if  need  be,  by  gentle  traction  on  the  leg.  Other- 
wise forceps  may  be  applied  as  soon  as  the  os  is  dilated  enough 
to  allow  their  easy  application.  In  rare  cases  craniotomy  may  be 
called  for,  especially  if  there  is  evidence  that  the  child  is  dead.  Of 
late  Cesarean  section  has  been  performed,  mostly  in  German3%  in  a 
considerable  number  of  cases  in  which  rapid  delivery  could  not 
otherwise  be  effected.  The  mortality,  however,  has  been  very  high 
(58*9  per  cent,  in  56  cases  collected  by  Hillman  and  Stevens 
and  55  per  cent,  in  34  cases  collected  by  Hammerschlag^),  and 
it  has  not,  therefore,  yet  been  proved  that  this  treatment  is  advis- 
able. Vaginal  Csesarean  section  would  seem  a  better  procedure 
(see  Chapter  XXXVL),  but  it  has  not  been  shown  that  even  this  is 
preferable  to  gradual  dilatation  of  the  cervix.  Diihrssen,^  however, 
maintains  that  it  is,  and  has  collected  112  cases  of  vaginal  Csesarean 
section  for  eclampsia  with  17  deaths,  or  a  mortality  of  15  per 
cent.,  while  ZweifeF  has  had  only  1  death  from  pneumonia  in 
33  cases  treated  by  this  method. 

In  the  convulsions,  care  should  be  taken  to  prevent  the  tongue 
being  bitten,  as  far  as  possible.  This  may  be  done  either  by  placing 
a  soft  folded  handkerchief  between  the  jaws,  so  as  to  depress  the 
tongue,  or  by  keeping  a  piece  of  cork  or  indiarubber  between  the 
molar  teeth. 

While  a  patient  is  comatose,  either  before  or  after  delivery,  no 
attempt  should  be  made  to  feed  by  the  mouth.  For  many  patients 
die  with  the  complication  of  broncho-pneumonia,  which  may  be  set 
up  by  liquid  food  getting  into  the  bronchi  when  a  patient  cannot 
swallow  j)roperly.  The  patient  should  be  kej)t  on  her  side  as  far  as 
possible,  so  as  to  avoid  the  continual  swallowing  of  the  mucus  which 
is  secreted. 

A  watch  should  be  kept  upon  the  temperature,  since  a  con- 
siderable elevation  of  it  is  of  the  gravest  prognosis.  If  it  rises 
to  a  very  high  point,  as  above  104°,  cold  should  be  applied  to 
the  head,  or,  if  necessary,  to  the  whole  body,  till  it  is  reduced. 
This  may  be  effected  by  an  ice-water  cap  or,  if  necessary,  by 
cold  sponging.  The  very  high  temperatures,  however,  are  rarely 
observed  when  the  fits  are  kept  in  check  by  morphia  or  chloroform, 

1  Zentralbl.  f.  Gynak.,  i:)04,  No.  36,  p.  1069. 

2  Diihrssen  :  Von  Winckd,  Handbucb  der  Gebuitshiilfe,  1906,  Bd.  3,  Th.  1,  p.  663. 

3  Zv/eifel,  Zentralbl.  f.  Gynak.,  1905,  No.  26,  p.  806. 


Disorders  of   Pregnancy.  491 

or  when  venesection  is  employed,  even  though  the  result  may- 
be fatal. 

If  there  are  any  signs  of  failure  of  the  heart  hypodermic  injections 
of  digitalin  or  camphor  should  be  given.  In  some  cases  where 
cyanosis  is  very  marked,  and  the  respiration  is  much  impeded, 
clearing  the  mouth  and  nose  of  mucus,  artificial  respiration,  and 
cardiac  massage  and  the  administration  of  oxygen  may  be 
required. 

After  delivery,  if  the  patient  is  to  recover,  the  interval  between 
the  fits  becomes  longer,  and  the  temperature  falls,  although  coma 
may  sometimes  continue  for  a  day  or  two.  Morphia  or  chloroform 
may  still  be  given,  if  fits  recur  frequently,  otherwise  this  is  the  most 
favourable  time  for  the  action  of  chloral  with  bromide  of  potassium, 
and  it  is  especially  in  this  class  of  cases  that  nephrotomy  and 
decapsulation  of  the  kidneys  has  been  suggested. 


Other  Disorders  produced  by  Mechanical  Causes. 

CEdema. —  Qj^dema  of  the  lower  limbs,  and  sometimes  of  the 
vulva,  is  a  common  result  of  the  pressure  of  the  gravid  uterus. 
The  tendency  to  cedema  is  increased  if  there  be  anaemia  in  addition. 
The  condition  is  not  of  much  consequence,  so  long  as  it  is  certain 
that  it  is  not  due,  in  part,  to  nephritis. 

Treatment, — Avoidance  of  standing  and  frequent  or  occasional 
rest  in  the  horizontal  position  should  be  enjoined.  The  bowels 
should  be  kept  acting  regularly,  to  prevent  an  increase  of  pressure 
on  the  veins  by  a  loaded  rectum  or  a  sigmoid  flexure,  but  violent 
or  hydragogue  purgatives  should  be  avoided,  as  tending  to  in- 
crease anaemia.  If  anaemia  is  present,  iron  may  be  given  with 
advantage. 

Varicose  Veins. — Varix  of  the  veins  of  the  legs,  thighs,  and 
sometimes  of  the  vulva  and  vagina,  is  also  a  result  of  pressure, 
especially  in  multiparas,  when  the  veins  have  been  subject  to 
repeated  distension  from  the  same  cause.  The  increased  volume 
of  the  blood  may  have  some  influence  in  the  causation  as  well  as 
the  local  pressure.  Sometimes  thrombosis  and  phlebitis  occur  in 
the  distended  veins,  especially  those  of  the  leg.  Instances  are  on 
record  of  fatal  haemorrhage  from  spontaneous  rujoture  of  a  vein 
in  the  leg,  or  laceration  by  violence  of  a  varicose  vein  of  the  vulva. 
If  a  vein  is  ruptured  beneath  the  mucous  membrane,  lueinatoiia  of 
the  vulva  is  produced.     This  will  be  considered  hereafter. 


49^  The  Practice  of   Midwifery. 

Treatment. — Varicose  veins  in  general  should  be  treated  by 
keeping  up  the  legs  as  much  as  possible,  administration  of 
laxatives,  and  the  use  of  elastic  stockings  or  bandages  for  the 
legs.  If  phlebitis  occurs,  the  recumbent  position  must  be  main- 
tained, and  anodyne  lotions  applied.  In  the  case  of  rupture  of  a 
vein,  firm  local  pressure  will  arrest  the  bleeding.  If  there  is  a 
very  superficial  and  localised  varix  of  the  vulva,  where  pressure  is 
not  available,  excision  of  the  veins  in  the  earlier  stage  of  pregnancy 
may  be  desirable. 

Hsemorrhoids. — The  passive  congestion  from  pressure  on  the 
rectal  veins,  added  to  the  active  congestion  which  prevails 
throughout  the  pelvis,  in  consequence  of  the  stimulus  of  the 
pregnant  uterus,  tends  to  the  production  of  haemorrhoids.  The 
tendency  is  often  greatly  increased  by  the  constipation  which  is  so 
common  in  pregnancy.  The  f£ecal  accumulation  compresses  the 
hsemorrhoidal  veins ;  violent  straining  further  increases  the  venous 
tension,  and  may  set  up  inflammation  in  the  haemorrhoids.  A 
similar  effect  may  be  produced  from  violent  straining  in  diarrhoea, 
or  from  the  action  of  too  strong  purgatives.  Internal  haemorrhoids 
are  liable  to  bleed  in  pregnancy,  sometimes  to  a  serious  extent. 
External  haemorrhoids,  which  are  the  commoner,  often  become 
inflamed,  and  cause  much  pain  in  defecation. 

Treatment. — The  general  treatment  is  to  give  gentle  laxatives, 
but  avoid  any  violent  purgatives.  The  laxatives  most  suitable 
for  use  in  pregnancy  have  already  been  mentioned  (see  p.  406). 
Aloes,  in  small  doses,  is  sometimes  useful,  although  in  large  doses 
it  is  especially  to  be  avoided,  on  account  of  its  special  action  upon 
the  rectum.  If  the  piles  are  external,  the  patient  should  avoid 
using  any  paper  after  defecation,  but  instead  of  this  take  a  vessel 
of  water  and  a  small  sponge  to  the  closet,  and  ^wash  with  the 
sponge.  The  water  may  be  hot  if  the  piles  are  inflamed,  other- 
wise cold.  For  inflamed  external  piles,  an  ointment  consisting  of 
equal  parts  Ung.  Zinci  Oxidi,  Ung.  Plumbi  Acetat.,  Ung.  Hydrarg. 
Nitrat.  Dilut.,  may  be  used.  The  distilled  extract  of  hamamelis 
(Pond's  extract  or  hazeline)  may  be  used  externally  undiluted,  may 
be  applied  by  means  of  a  piece  of  unpurified  sheep's  wool  soaked  in 
the  lotion  and  introduced  just  within  the  anus,  or  may  be  injected 
into  the  rectum,  diluted  with  two  parts  of  water,  by  means  of  the 
ordinary  glycerine  injection  syringe,  holding  two  drachms.  Opera- 
tions on  the  haemorrhoids  during  pregnancy  will  generally  only  be 
advisable  if  there  is  serious  haemorrhage,  which  cannot  otherwise 
be  checked. 


Chapter  XXI. 
ABNORMALITIES  OF  THE  UTERUS. 

Congenital  Malformations  of  Uterus  and  Vagina. — The  case 
of  pregnancy  in  a  rudimentary  uterine  horn,  leading  to  rupture, 
has  been  already  described  (see  p.  436).  When  the  uterus  consists 
of  one  developed  half  only  (uterus  unicornis),  and  pregnancy  occurs 
in  it,  the  course  of  pregnancy  and  labour  is  usually  normal.  Several 
varieties  occur  of  double  uterus  or  vagina.  Both  vagina  and  uterus 
may  be  double  (see  Figs.  236,  237,  pp.  375,  376),  the  vagina  maybe 
single  and  whole  uterus  double,  the  uterus  may  have  a  single  cervix 
and  double  body  (see  Fig.  238,  p.  376),  or  the  body  may  be  only  par- 
tially divided.  In  all  these  conditions  pregnancy  is  possible  on  one 
or  both  sides,  and  generally  goes  on  to  a  normal  termination.^  The 
possibility  of  superfcetation  in  a  double  uterus  has  already  been 
considered  (see  p.  376).  Labour  may  be  retarded  when  the  uterus 
is  double,  from  weakness  of  the  muscular  wall,  from  deviation  of  the 
uterine  axis,  or  from  the  other  side  forming  an  obstruction.  In 
one  case  I  have  known  the  head  of  the  child  to  get  into  the  second 
half  of  a  double  uterus  {uterus  bicornis  unicollis),  and  form  a  mass 
in  the  pelvis,  preventing  the  progress  of  labour,  and  necessitating 
Csesarean  section,  which  was  successfully  performed.  I  have  found 
the  placenta  retained,  and  very  difficult  to  reach,  at  the  extremity 
of  a  long  diverging  horn.  From  a  similar  cause,  j^ost-jMi'tum 
haemorrhage  may  occur.  In  cases  where  the  uterus  is  only  partially 
divided  (uterus  cordiformis),  transverse  presentations  are  especially 
frequent.  When  the  body  of  the  uterus  is  double,  and  one  side 
pregnant,  a  decidua  is  formed  on  the  unimpregnated  side,  and  is 
generally  expelled  after  delivery.  This  may  be  the  only  sign  which 
calls  attention  to  the  fact  of  some  abnormality  existing.  The  exact 
character  of  the  abnormality  is  best  made  out  just  after  delivery, 
when  the  exterior  of  the  uterus  can  be  easily  manipulated  through 
the  relaxed  abdominal  walls,  and  the  finger  can  l)e  introduced  into 
the  interior. 

'  Giles,  Trans.  Obst.  Soc,  London,  190.5,  Vol.  XXXVII.,  p.  .SOI. 


494 


The  Practice  of   Midwifery. 


DISPLACEMENTS    OF    THE    UTEEUS    AND   VAGINA. 

Anteversion  and  Anteflexion. — In  the  early  months  of  preg- 
nancy there  is  usually  some  increase  in  the  normal  anteflexion  of 
the  uterus,  and  its  anteversion  in  reference  to  the  axis  of  the  brim, 
the  bladder  being  empty  or  nearly  empty,  in  consequence  of  the 
increased  weight  of  the  fundus.  Sometimes  these  conditions  are 
exaggerated,  especially  when  the  uterus  has  been  anteverted  or 
anteflexed  before  impregnation.  Generally  the  symptoms  are  slight, 
but  some  irritability  of  bladder  or  rectum  may  result  from  pressure 


Fig.  270. — Figure  showing  position  of  uterus  with  a  pendulous  abdomen. 

of  the  fundus  upon  the  former,  and  of  the  cervix  upon  the  latter. 
It  was  considered  by  Dr.  Graily  Hewitt,  that  anteflexion  in  early 
pregnancy  is  the  chief  cause  of  vomiting,  and  has  a  strong  tendency 
to  lead  to  abortion,  but  these  conclusions  have  not  been  generally 
accepted.  It  is  not  possible  for  the  fundus  to  become  incarcerated 
in  anteflexion  as  it  does  in  retroflexion,  unless  some  other  morbid 
condition,  such  as  a  fibroid  tumour,  co-exists.  As  the  uterus 
enlarges,  the  fundus  rises  out  of  the  pelvis,  above  the  level  of  the 
pubea. 

In  the  later  months  of  pregnancy,  anteversion,  generally  com- 
bined with  anteflexion,  appears  in  a  different  form,  and  leads  to  the 
condition  known  as  pendulous  belly.      It  is  generally  due  to  the 


Abnormalities  of  the   Uterus.  495 

laxity  of  the  abdominal  walls  in  multiparse.  The  heavy  fundus 
hangs  forward  over  the  pubes,  so  that  the  front  of  the  fundus  may 
be  at  a  lower  level  than  the  centre  of  the  uterus.  In  extreme  cases 
the  recti  are  widely  separated,  so  that  the  fundus  forms  a  kind  of 
hernia,  covered  only  with  skin,  fascia,  and  connective  tissue.  This 
disj)lacement  is  promoted  by  contraction  of  the  pelvis — and  this  is 
its  most  common  cause  in  primiparse — sufficient  to  prevent  the  head 
from  lying  in  the  pelvic  cavity,  by  any  deformity  which  diminishes 
the  space  between  the  pelvis  and  the  ribs,  so  that  there  is  not  room 
for  the  axis  of  the  uterus  to  lie  in  its  usual  position,  and  by  lordosis 
of  the  lumbar  vertebrae,  which  pushes  the  posterior  wall  of  the 
uterus  forward. 

When  the  displacement  is  considerable,  there  is  difficulty  in 
walking,  dragging  pain  from  the  stretching,  sometimes  irritability 
of  the  bladder  from  the  pressure  uj)on  it,  sometimes  oedema  at  the 
lower  part  of  the  abdominal  wall.  There  is  a  tendency  to  abnormal 
presentations  of  the  foetus  from  the  altered  influence  of  gravity,  and 
in  very  marked  cases  dilatation  of  the  cervix  during  labour  takes 
place  very  slowly  or  may  even  be  wanting  entirely.-^ 

Treatment. — Little  or  no  treatment  is  usually  required  for  ante- 
version  or  anteflexion  in  the  early  months.  Moderate  rest  in  the 
dorsal  position  may  be  emjDloyed,  and,  if  necessary,  a  hypogastric 
belt  may  be  worn  when  the  fundus  has  begun  to  rise  above  the 
pubes.  Ante  version  pessaries  are  not  to  be  recommended  in 
pregnancy.  For  the  displacement  in  the  later  months,  a  firm 
abdominal  belt  should  be  worn,  carrying  the  fundus  backward  and 
upward. 

In  cases  of  anteversion  and  anteflexion,  where  the  uterus  is  more 
or  less  fixed  as  the  result  of  the  operations  of  vaginal  fixation, 
ventral  suspension,  or  ventral  fixation,  complications  may  arise  both 
during  pregnancy  and  labour.  These  are  especially  likely  to  occur 
when  the  uterus  is  firmly  attached  to  the  bladder  or  to  the  anterior 
abdominal  wall.  During  pregnancy  the  patient  may  complain  of 
pain  due  to  the  stretching  of  the  adhesions,  and  as  the  ovum  grows 
the  uterus  may  develop  entirely  at  the  expense  of  its  posterior  wall, 
the  anterior  remaining  undeveloped ;  at  the  same  time  upward 
displacement  of  the  cervix  may  take  place  to  an  excessive  degree, 
and  when  labour  sets  in  dilatation  of  the  cervical  canal  may  not 
occur  at  all  or  very  imperfectly.  In  such  circumstances  there  will 
be  a  considerable  risk  of  the  occurrence  of  rupture  of  the  uterus. 
Attempts  have  been  made  to  avoid  any  such  complications  by 
practising,  in  patients  who  are  likely  to  become  pregnant,  ventral 

1  li,  V.  J'.iauii  Fornwald,  Zentralbl.  f.  Gyniik.,  1898,  No.  19,  s.  489. 


49^  The  Practice  of   Midwifery. 

suspension  rather  tlian  ventral  fixation  or  by  passing  the  attaching 
sutures  through  the  lower  uterine  segment  only.  As  Whitridge 
Williams,  however,  has  shown,  difficulty  may  arise  even  when  the 
operation  of  ventral  suspension  has  been  carried  out  by  competent 
surgeons.  Thus  he  has  recorded  two  cases  in  which  Cesarean 
section  was  required  and  one  in  which  craniotomy  was  performed  for 
dystocia  occurring  in  patients  upon  whom  this  operation  had  been 
performed.  He  further  collected  thirty-six  cases  where  Cesarean 
section  was  required,  and  three  cases  of  craniotomy  in  patients 
suffering  from  dystocia  the  result  of  one  or  other  of  these  operations. 
Ventral  fixation  or  ventral  suspension  therefore  should  not  be 
performed  in  patients  who  are  likely  to  become  pregnant. 

Retroflexion  and  Retroversion. — These  are  by  far  the 
gravest  displacements  of  the  pregnant  uterus.  In  the  great 
majority  of  cases  the  version  and  flexion  are  combined.  A  per- 
fectly straight  retroverted  gravid  uterus  is  hardly  found,  except 
in  the  rare  cases  in  which  the  displacement  is  produced  suddenly 
by  violence  or  strain.  In  some  cases,  however,  the  version,  and 
in  others  the  flexion,  is  the  prominent  element.  Eetroflexion 
entirely  without  retroversion  rarel}^  if  ever,  occurs,  for  the  cervix 
is  almost  always  tilted  forward  more  or  less.  Retroversion  with 
retroflexion,  in  its  complete  form,  cannot  exist  beyond  about  the 
end  of  the  fourth  or  the  middle  of  the  fifth  month  of  pregnancy, 
for,  after  that,  the  fundus  is  too  large  to  be  contained  in  the  pelvis. 

Causation. — This  displacement  arises  as  a  rule  out  of  a  previous 
displacement  of  an  unimpregnated  uterus.  In  the  great  majority 
of  cases,  the  displacement  has  become  gradually  aggravated  in 
consequence  of  the  growth  of  the  uterus.  Before  pregnancy  the 
uterus  has  been  either  retroverted,  or,  more  frequently,  in  the 
commoner  condition  of  retroflexion  combined  with  retroversion. 
In  either  case  there  has  been  more  or  less  of  that  partial  prolapse 
which  is  the  almost  invariable  antecedent  and  accompaniment  of 
retroversion.  Pregnancy  having  occurred,  the  growing  fundus 
begins  to  press  upon  surrounding  parts.  In  a  considerable  pro- 
portion of  cases  of  this  kind  the  uterus  eventually  rights  itself 
spontaneously,  and  the  fundus  rises  out  of  the  hollow  of  the 
sacrum  into  the  abdomen.  The  mechanism  by  which  this  happens 
appears  to  depend  upon  the  fact  that  the  state  of  the  pregnant 
uterus  is,  to  some  extent,  plastic,  and  yields  gradually  to  continuous 
pressure,  while  at  the  same  time  the  cervix  forms  a  fixed  point  under 
the  symphysis  pubis.  Thus,  being  pressed  upon  on  all  sides  in  the 
pelvis,  as  it  enlarges,  it  expands  in  the  direction  of  least  pressure, 


Abnormalities  of  the   Uterus. 


497 


that  is,  toward  the  pelvic  brim,  until  at  length  the  fundus  is  able 
to  get  above  the  promontory  of  the  sacrum. 

If  this  spontaneous  rectification  does  not  occur,  just  the  reverse 
generally  happens,  and  the  displacement  becomes  aggravated,  the 
element  of  retroversion  more  especially  being  increased,  so  that 
the  cervix  is  tilted  more  and  more  forward  and  upward,  stretching 
the  anterior  vaginal   wall  and  the  urethra.     This  is  due  to  the 


Fig.  271. — Incarceration  of  the  retroflexed  gravid  uterus  with  rupture  of  the 
bladder  from  over-distension.  (Univ.  Coll.  Hosp.  Med.  School  Mus., 
Spec.  No.  4251.) 


fact  that  the  presence  of  the  enlarged  displaced  fundus  excites 
bearing- down  efforts  by  which  it  is  forced  lower  and  lower,  and 
the  cervix  thereby  tilted  forward  and  upward.  Sometimes  the 
fundus  comes  low  enough  actually  to  rest  upon  the  perineum, 
and  it  has  even  been  known  to  distend  the  anus.  Toward  the 
end  of  the  third  month  the  uterus  begins  to  be  so  large  that 
the  fundus,  lying  from  the  first  in  the  hollow  of  the  sacrum,  is 
detained  under  the  sacral  promontory,  and  is  unable  to  rise  above 
it,  since  the  antero-posterior  diameter  of  the  pelvic  brim  is  less 
M.  32 


498  The  Practice  of   Midwifery. 

than  that  of  the  pelvic  cavity  (see  p.  17).  In  this  way  arises 
incarceration  of  the  retroverted  gravid  uterus.  Its  pressure  on 
surrounding  parts  grows  greater  ;  the  cervix  is  pushed  more  and 
more  forward  and  upward,  since  the  fundus  cannot  rise,  and 
eventually  a  stage  is  reached  at  which  the  pressure  of  the  cervix 
on  the  neck  of  the  bladder,  generally  combined  with  the 
stretching  upward  of  the  urethra,  causes  retention  of  urine 
(Fig.  271).  "     • 

Though  this  gradual  mode  of  origin  is  the  rule,  in  rate  cases 
the  displacement  arises  suddenly.  Either  a  fall  on  the  back,  or  a 
sudden  muscular  strain  or  bearing-down  effort,  forces  the  fundus 
down  into  the  hollow  of  the  sacrum.  If  this  happens  toward  the 
end  of  the  third,  or  in  the  fourth  month  of  pregnancy,  the  fundus 
will  be  so  large  that  it  cannot  easily  rise  again,  and  then  the 
symptoms  of  incarceration  come  on  suddenly  or  rapidly.  Even 
this  sudden  mode  of  origin,  however,  implies  a  previous  partial 
displacement.  The  fundus  must  have  been  inclined  more  back- 
wards than  normal,  though  not  in  the  hollow  of  the  sacrum, 
otherwise  the  abdominal  pressure  would  have  acted  on  its 
posterior,  not  on  its  anterior  surface,  and  would  only  have  brought 
it  into  increased  anteversion.  Such  inclination  of  the  fundus 
backward  would  be  greater  if  the  bladder  happened  to  be  full  at  the 
time  when  the  sudden  strain  or  fall  took  place. 

Diirhrssen  maintains  that  cases  of  incarceration  of  the  retroverted 
gravid  uterus  are  most  commonly  due  to  a  sudden  fall  or  blow,  and 
that  in  these  cases  the  symptoms  do  not  appear  so  early  as  in  cases 
of  retroflexion.  As  the  cervix  points  almost  directly  upwards  the 
lower  uterine  segment  is  able  to  grow  and  expand  in  the  direction 
of  the  pelvic  inlet.  This  continues  until  the  stretching  of  the 
vaginal  walls  which  occurs  reaches  its  maximum,  and  then  the 
cervix  begins  to  press  upon  the  bladder,  and  so  causes  the  reten- 
tion of  urine.  In  these  cases  the  bladder  may  become  almost 
divided  into  two  separate  pouches  by  the  projection  of  the  cervix 
into  it. 

Results.— 'Ha.tnve' 8  readiest  mode  of  relief  is  the  occurrence  of 
abortion.  This  may  happen  before  the  uterus  is  large  enough  to 
cause  incarceration.  Thus,  if  a  series  of  abortions  before  the  end 
of  the  third  month  has  occurred,  without  any  apparent  cause,  and 
an  examination  of  the  woman  is  made,  the  cause  is  sometimes 
revealed  in  retroflexion  of  the  uterus,  and  future  pregnancies  pro- 
ceed normally,  when  the  displacement  has  been  rectified.  When 
the  uterus  is  incarcerated,  and  pressure  becomes  severe,  the 
tendency  to  abortion  is  possibly  increased. 


Abnormalities  of  the   Uterus.  499 

Herman/  however,  has  collected  115  cases  of  which  only  five 
aborted,  or  1  in  25. 

After  abortion,  the  flexion  of  the  uterus  is  apt  to  interfere  with 
the  complete  evacuation  of  the  ovum,  unless  the  evacuation  is 
artificially  completed.  From  retention  of  a  portion  of  ovum  may 
arise  saprsemia,  or  possibly  even  septicsemia. 

As  soon  as  retention  of  urine  is  produced,  grave  danger  arises  if 
the  case  is  not  promptly  treated.  The  bladder  becomes  greatly 
distended,  often  rising  above  the  level  of  the  umbilicus.  Some- 
times it  has  been  mistaken  for  an  ovarian  tumour.  Eventually 
the  tension  is  somewhat  relieved  by  some  of  the  urine  dribbling 
away  (so-called  imracloxical  incontinence).  The  retained  urine 
soon  decomposes,  and  sets  up  cystitis.  When  drawn  off,  it  may 
be  found  bloody  and  intensely  foetid  and  ammoniacal.  Sometimes 
the  inflammation  of  the  bladder  is  so  severe  as  to  cause  sloughing 
of  part,  or  even  of  the  whole  thickness,  of  its  wall.  Casts  consisting 
of  mucous  membrane,  or  mucous  membrane  and  muscle  tissue,  or 
even  in  very  rare  cases  of  the  whole  thickness  of  the  bladder  wall 
have  been  expelled.  The  pressure  extends  backward  to  the  kidneys, 
and  may  set  up  albuminuria  and  uraemia.  The  septic  inflammation 
may  also  extend  backward  to  the  kidneys,  and  lead  to  septic 
nephritis  and  the  so-called  "  surgical  kidney."  Karely  the  bladder 
ruptures,  or  gives  way  by  ulceration,^  and  rarely,  also,  peritonitis 
arises.  The  most  frequent  cause  of  a  fatal  result  is  the  inflam- 
mation of  bladder  and  kidneys.  A  case  has  also  been  recorded 
in  which  pressure  on  the  colon  caused  ulceration  and  gangrene  of 
the  gut.^ 

Even  when  the  stage  of  incarceration  has  been  reached,  a  natural 
termination  is  possible,  without  the  occurrence  of  abortion,  provided 
the  dangers  arising  from  retention  of  urine  are  averted  by  the 
catheter  being  used  whenever  required.  The  plastic  uterus  gradu- 
ally accommodates  itself  by  expanding  upwards  in  the  direction  of 
the  pelvic  brim,  the  only  direction  in  which  expansion  is  possible, 
until  it  has  reached  a  sufficient  size  to  allow  the  major  part  of  the 
foetus  to  rise  out  of  the  pelvis  into  the  abdomen.  It  appears  that, 
during  this  process,  the  fundus  uteri  gradually  rises  into  the 
abdomen,  escaping  past  the  promontory  of  the  sacrum  by  gradual 
growth  rather  than  sudden  movement,  and  that,  at  any  rate  in 
most  such  cases,  the  uterus  thus  eventually  rights  itself,  although 
for  some  time,  and  perhaps  even  to  full  term,  a  bulging  pouch, 

1  Herman,  Brit.  Med.  Jouin.,  1904,  Vol.  I.,  p.  877. 

2  Haultaiii,  Kdin.  Med.  .louni.,  June,  18!)0,  Vol.  XXXV.,  p.  1122. 

«  Treub,  quoted  by  Dienat,  Deutsch.  Med.  Wochenschr.,  April  2Uth,  1905,  p.  ()23. 

32—2 


500 


The  Practice  of   Midwifery. 


consisting  of  the  lower  portion  of  the  jDosterior  uterine  wall,  may 
still  be  felt  in  the  pelvis  behind  the  cervix. 

E.  Barnes  describes  an  incomplete  retrofiexion,  or  sacculation  of 
the  uterus,  as  persisting  in  some  cases  to  full  term,  the  uterus  being 
converted  into  two  pouches,  a  pelvic  pouch  containing  the  head  or 
breech,  and  an  abdominal  pouch  containing  the  bulk  of  the  foetus, 
the  cervix  remaining  displaced  forwards  and  upwards  above  the 
symphysis  pubis  (Fig.  272).     He  considers  that  this  condition  is 


Fig.  272.— Gradual  development  of  anterior  wall  of  uterus  in  a  case  of 
incomplete  retroflexion  of  the  uterus. 

developed  out  of  a  retroflexion  in  the  early  months  by  a  pouch-like 
diverticulum  being  formed  from  the  upper  surface — that  is,  the 
original  anterior  wall— of  the  uterus,  which  eventually  becomes  the 
abdominal  pouch,  receiving  the  greater  bulk  of  the  fcetus.  In 
most  cases  this  condition  comes  under  observation  only  when  labour 
comes  on,  and  its  progress  is  arrested  on  account  of  the  displaced 
position  of  the  os. 

Symptoms. — For  the  first  month  or  two  there  may  be  little  or 
no  symptom,  but  generally  there  is  an  increase  of  the  symptoms 
previously  associated  with  the  retroflexion,  especially  bearing-down 


Abnormalities  of  the   Uterus.  501 

pain  in  the  pelvis,  chiefly  towards  the  back,  and  pain  and  difficulty 
in  defecation  ;  usually  constipation  is  marked ;  sometimes  there  is 
leucorrhoea,  sometimes  irritability  of  bladder.  .  Then,  generally 
before  the  end  of  the  third  month,  or  early  in  the  fourth  month, 
retention  of  urine  is  produced.  This  generally  happens  the  later, 
the  greater  is  the  amount  of  room  in  the  pelvis.  Often  it  begins 
rather  suddenly,  perhaj)s  in  consequence  of  some  strain  or  bear- 
ing-down effort.  The  distress  then  quickly  becomes  considerable  ; 
the  symptoms  of  pelvic  pressure  are  increased,  but  the  most  acute 
pain  is  due  to  the  condition  of  the  bladder.  Eeflex  symptoms  are 
excited  by  the  presence  of  the  displaced  fundus  like  a  foreign  body 
pressing  upon  the  rectum.  These  chiefly  take  the  form  of  bearing- 
down  efforts,  by  which  the  mischief  is  aggravated.  Sometimes 
interference  with  the  bowels  and  partial  obstruction  lead  to 
nausea  and  vomiting.  Later  constitutional  disturbance  with 
pyrexia  is  produced  by  the  decomposition  of  the  urine,  the  inflam- 
mation of  the  bladder,  and  finally  the  damage  to  the  kidneys, 
which  may  lead  to  ursemic  symptoms.  Pain  indicative  of  peritonitis 
is  rare,  but  pain  from  distension  and  inflammation  of  bladder,  with 
pelvic  pressure,  may  be  severe  and  agonising  without  the  existence 
of  any  peritonitis. 

When  the  retroversion  is  suddenly  produced  as  the  result  of  a 
fall  or  strain,  the  acute  symptoms  of  pressure  come  on  suddenly, 
and  there  may  be  in  addition  the  symptoms  of  shock,  pallor,  rapid 
feeble  pulse,  sometimes  nausea  and  vomiting. 

Diagnosis. — The  most  characteristic  and  constant  symptom  is 
that  of  retention  of  urine  combined  with  amenorrhoea  of  about 
three  months.  In  any  case  of  retention  of  urine,  where  pregnancy 
is  possible,  inquiry  should  be  made  about  the  state  of  menses,  and 
the  likelihood  of  retroversion  of  the  gravid  uterus  be  borne  in 
mind.  It  must,  of  course,  be  remembered  that  haemorrhage  may 
occur  if  abortion  is  threatened,  but,  if  pregnancy  exists,  there  will 
generally  have  been  some  amenorrhoea.  Sometimes  the  complaint 
made  is  not  of  retention,  but  of  inability  to  hold  the  urine,  this 
condition  being  due  to  the  dribbling  away  of  the  urine  from  the 
distended  bladder. 

The  abdomen  may  probably  be  found  occupied  by  the  distended 
bladder.  The  nature  of  this  swelling  will  be  cleared  up  by  the 
use  of  the  catheter,  and  an  examination  of  the  breasts  will  lead  to  a 
suspicion  of  pregnancy.  On  vaginal  examination,  after  the  bladder 
has  been  emptied,  the  rounded  swelling  behind  the  cervix  formed 
by  the  pregnant  fundus  will  have  to  be  distinguished  from  other 
swellings  which  may  be  situated  there.     It  will  be  larger  than  in 


502  The  Practice  of   Midwifery. 

the  case  of  retroflexion  of  the  un impregnated  fundus.  The  occur- 
rence of  amenorrhoea,  changes  in  the  breasts,  and  other  signs  of 
pregnancy,  will  help  the  diagnosis.  Less  will  be  felt  of  the  fundus 
uteri  from  the  hypogastrium  than  should  be  felt  in  correspondence 
with  the  date  of  pregnancy  ;  and  on  bimanual  examination,  the 
complete  absence  of  the  fundus  from  its  normal  position  in  front 
may  be  made  out.  The  continuity  of  the  swelling  behind  with  the 
cervix,  and  the  conjoint  movement  of  the  two,  may  also  generally 
be  ascertained. 

The  case  of  a  tumour  behind  the  uterus  will  generally  be  dis- 
tinguished by  the  condition  of  the  cervix.  In  retroflexion  of  the 
gravid  uterus,  there  is  almost  always  some  retroversion  also  ;  the 
cervix  is  tilted  more  or  less  forward  and  displaced  upward  as  well 
as  forward,  so  as  to  put  the  anterior  vaginal  wall  and  urethra  on  a 
stretch.  When  the  uterus  is  pushed  forward  by  a  tumour  behind, 
the  cervix  is  generally  lower  down,  and  looks  more  nearly  in  its 
normal  direction.  Of  these  two  signs,  the  direction  of  the  cervix 
is  the  more  important,  for  the  cervix  may  be  drawn  upward  in  the 
case  of  fibroid  or  ovarian  tumour.  In  the  case  of  tumour,  the 
fundus  may  also  be  made  out,  on  bimanual  examination,  as  lying 
in  front.  The  tumours  most  likely  to  lead  to  error,  when  found 
behind  the  cervix,  are  small  ovarian  or  fibroid  tumours,  or  the  sac 
of  an  extra-uterine  foetation,  the  last  being  especially  likely  to  cause 
a  mistake.  Eetro-uterine  hfematocele  and  inflammatory  swellings 
have  also  to  be  distinguished. 

In  some  cases  the  retroflexed  pregnant  fundus  may  be  detected 
as  varjdng  in  hardness,  in  consequence  of  the  rhythmical  con- 
traction of  the  uterus  during  pregnancy.  The  softening  of  the 
cervix  will  often  aid  in  distinguishing  the  case  from  one  of  a 
tumour  displacing  the  unimpregnated  uterus.  Sometimes  the 
diagnosis  can  be  at  once  completed  by  restoring  the  fundus  to 
its  place. 

In  a  case  of  sacculation  or  j)artial  retroflexion  of  the  uterus  the 
diagnosis  may  be  difficult  owing  to  the  extremely  oedematous  and 
thickened  condition  of  the  sacculated  portion. 

Treatment. — In  the  early  stage,  before  incarceration  has  taken 
place  or  retention  of  urine  has  been  produced,  it  is  generally  easy 
to  replace  the  uterus.  The  patient  should  be  placed  in  the  semi- 
prone  position.  First  the  finger  in  the  posterior  cul-de-sac  of  the 
vagina  pushes  the  fundus  upward  as  far  as  it  can  reach  ;  next  the 
finger  is  transferred  to  the  cervix  and  carries  the  cervix  well  back- 
ward into  the  cavity  of  the  sacrum.  By  this  means  the  fundus 
will  be  brought  still  further  forward.     Either  a  full-sized  Hodge's 


Abnormalities  of  the   Uterus.  503 

pessary  or  an  elastic  ring^  pessary  should  then  be  introduced. 
The  object  is  to  maintain  or  complete  the  restoration  of  the 
uterus  rather  by  holding  the  cervix  backward  than  by  directly 
pushing  the  fundus  upward.  This  is  easier  in  the  case  of  the 
pregnant,  than  in  that  of  the  unimpregnated  uterus,  partly  because 
the  organ  is  larger,  and  partly  because  it  has  a  natural  tendency 
to  straighten  itself  in  pregnancy  when  opposing  forces  do  not 
prevent  this. 

If  incarceration  and  retention  of  urine  have  already  been  pro- 
duced, the  first  thing  is  to  empty  the  bladder,  and  the  rectum  also 
by  enema,  if  there  is  any  collection  of  faeces.  A  soft  rubber 
catheter  should  be  employed,  or  if  this  does  not  succeed  a  No.  8 
male  gum  elastic  catheter  may  be  tried.  After  this,  if  the 
symptoms  have  been  acute  and  are  now  relieved,  and  if  there  is  no 
immediate  threatening  of  abortion,  it  is  often  a  good  plan  to  keep 
the  patient  in  bed  for  a  day  or  two,  and  continuously  in  the 
semi-prone  position,  the  bladder  being  emptied  regularly,  to  see 
whether  spontaneous  restoration  will  occur.  If  not,  the  attempt 
should  be  made  to  restore  the  uterus,  or  this  plan  may  even 
be  adopted  at  the  outset.  I  have  hardly  ever  found  this  treat- 
ment by  immediate  reduction  either  fail  to  succeed,  or  lead  to  any 
inconvenient  result.  It  requires,  however,  some  dexterity  in 
manipulation. 

Great  assistance  is  derived  from  the  knee-elbow  position.  The 
patient  is  made  to  kneel  on  a  flat  couch  so  that  her  chest,  as  nearly 
as  possible,  touches  the  surface  of  the  couch,  and  the  thighs  are 
perfectly  vertical.  This  position  makes  the  brim  of  the  pelvis 
look  almost  vertically  downward.  When  the  labia  are  separated, 
air  enters  the  vagina  and  distends  it  into  a  wide  cavity,  and  the 
contents  of  the  pelvis  are  drawn  toward  the  abdomen,  not  only  by 
their  own  gravity,  but,  in  a  measure,  by  that  of  the  abdominal 
contents,  which  produces  a  negative  pressure  (i.e.,  a  pressure  less 
than  that  of  the  atmosphere)  in  the  portion  of  the  abdomen  now 
most  elevated. 

In  an  easy  case  the  uterus  is  restored  from  the  vagina  with  least 
discomfort  to  the  patient.  Two  fingers  are  introduced  into  the 
posterior  cul-de-sac,  and  placed  upon  the  fundus  as  far  back  as 
possible.  The  fundus  is  then  pushed  toward  the  abdomen  as  far 
as  the  fingers  will  reach,  not  directly  upward,  but  toward  the  side 
to  which  the  fundus  is  already  inclined  in  order  to  avoid  the  pro- 
montory of  the   sacrum.     This  will  generally  be  toward  the  right 

1  'J'he  best  form  of  ring  pessary  is  that  made  of  watch-spring  covered  with  iiidiarubbcr, 
the  diameter  of  the  section  of  the  rubber  being  not  less  than  about  half  an  inch. 


504  The  Practice  of   Midwifery. 

side.  Meanwhile  counter-pressure  may  be  made  upon  the  cervix, 
or  opposite  pole  of  the  uterus,  by  the  other  hand  placed  on  the 
abdominal  wall  just  above  the  pubes,  or  the  cervix  may  be  drawn 
down  by  a  vulsellum,  care  being  taken  not  to  tear  the  tissue  softened 
by  the  pregnancy.  As  soon  as  the  fundus  has  receded  to  the  full 
length  of  the  fingers,  the  fingers  should  be  transferred  to  the  cervix, 
and  carry  this  fully  back  into  the  hollow  of  the  sacrum,  before  the 
patient  is  allowed  to  lie  down  upon  her  side.  If  the  fundus  has 
been  fully  restored,  it  will  generally  remain  in  position ;  if  only 
partially,  the  displacement  recurs  at  once,  or  after  a  short  time. 

Restoration  by  Rectum.— li  pressure  from  the  vagina  does  not 
easily  succeed,  pressure  from  the  rectum  should  be  tried.  This 
allows  the  fingers  to  reach  further  back  and  more  completely  to 
the  fundus,  and  so  affords  a  greater  leverage.  The  fingers  can  also 
thus  reach  higher  in  the  pelvis,  especially  when  the  vagina  is  not 
lax.  One  or  two  fingers  should  be  passed  into  the  rectum,  the 
knee-elbow  position  being  used  as  before,  and  the  manipulation 
carried  out  in  precisely  the  same  way  as  from  the  vagina.  Some 
prefer  to  give  an  anresthetic  and  place  the  patient  in  the  semi-prone 
position.  With  a  nervous  patient,  this  plan  may  be  adopted ; 
otherwise  I  have  found  the  advantage  of  the  anaesthetic  to  be  less 
than  that  of  the  knee-elbow  position.  But  in  any  case,  if  the 
attempt  fails,  the  patient  should  be  placed  under  anaesthesia,  and 
taxis  again  tried,  either  in  the  semi-prone  or  the  dorsal  position, 
whichever  is  found  most  convenient.  No  undue  force  must  be 
used,  and  in  any  case  where  signs'of  sloughing  of  the  bladder  wall 
are  present  forcible  efi'orts  at  replacement  must  be  avoided.  After 
the  replacement,  the  patient  should  be  kept  in  bed  for  a  day  or  two, 
and  an  opiate  given,  lest  abortion  should  come  on  afterwards. 

Elastic  Pressure. — If  digital  rej)lacement  fails,  the  method  of 
gradual  pressure  should  be  tried.  This  is  best  efl'ected  by  the 
introduction  of  a  ring  pessary  as  large  as  possible  into  the  vagina, 
as  suggested  by  Sinclair,^  and  this  alone  is  often  sufficient  to  over- 
come the  displacement.  Or  an  air-ball  pessary  may  be  placed  in  the 
vagina,  as  far  back  toward  the  fundus  as  possible,  and  its  inflation 
increased  from  time  to  time  by  means  of  the  air-pump  with  which 
it  is  fitted,  unless  there  are  grave  constitutional  symptoms,  since 
spontaneous  restoration  practically  always  occurs  if  the  bladder  be 
kept  emptied.  If  there  are,  it  may  be  advisable  to  induce  abortion. 
If  possible,  a  sound  or  stylet  should  be  passed  through  the  os,  so  as 
to  rupture  the  membranes.  If  this  proves  impossible,  as  is  most 
likely  in  cases  of  pure  retroversion,  owing  to  the  extreme  displace- 

1  Sinclair,  Trans.  Obst.  Soc.  London,  1900,  Vol.  XLII.,  p.  338. 


Abnormalities  of  the   Uterus. 


505 


ment  of  the  os,  it  has  been  recommended  to  draw  off  the  liquor 
amnii  by  puncturing  from  the  vagina  with  an  aspirator  needle,  but 
I  have  never  known  this  to  be  necessary.  The  uterus  will  right 
itself  to  a  considerable  extent  at  any  rate,  as  it  expels  its  contents. 

Abdominal  Section. — An  alternative  is  to  perform  abdominal 
section,  separate  any  adhesions  which  may  exist,  and  restore  the 
uterus  to  position.  This  procedure  has  been  carried  out  success- 
fully in  a  number  of  cases,  but  will  rarely  be  necessary  if  the  other 
means  are  properly  tried,  and  should  only  be  resorted  to  as  a  last 
resource,  unless  there  is  evidence  of  the  presence  of  adhesions  or  of 
serious  damage  to  the  bladder. 

The  treatment   of  the   partial   retroflexion,    real    or   supposed, 
continuing  up  to  labour  at  full 
term,  will  be  considered  hereafter 
(Chapter  XXVIL). 

The  use  of  any  pessary  intro- 
duced in  the  early  months 
should  generally  be  continued 
up  to  about  the  end  of  the  fourth 
month.  After  that  time  the 
fundus  uteri  becomes  too  large 
to  descend  again  into  the  pelvis, 
and  the  pessary  should  therefore 
be  removed. 


Fig.  27;^. — Prolapse  of  second  degree  in 
unimpregnated  uterus. 


Prolapse  of  the  Uterus  and 
Vagina. — Prolapse  of  the  uterus 
may  be  real  in  the  early  months 
of  pregnancy,  or  ifc  may  be  apparent,  being  really  elongation  of  the 
cervix ;  or  again  there  may  be  that  condition  which  in  apparent 
procidentia^  of  the  unimpregnated  uterus  is  the  commonest,  namely, 
an  elongation  of  the  supra-vaginal  cervix  combined  with  descent  of 
the  whole  uterus  (see  Fig.  273).  Prolapse  of  the  uterus  is  not  very 
common  in  pregnancy,  considering  the  frequency  with  which  it 
occurs  apart  from  pregnancy.  For  the  prolapse  is  to  some  extent  a 
hindrance  to  pregnancy,  and  pregnancy,  when  it  does  occur,  has  a 
tendency  eventually  to  cure  the  prolapse.  The  uterus,  as  it 
enlarges,  generally  rises  out  of  the  pelvis,  and  eventually  rests 
upon  the  brim. 

Causation. — All  forms  of  prolapse  of  uterus  and  vagina,  as  might 
be  expected,  occur  chiefly  in  women  who  have  been  pregnant  before. 
Prolapse  of  the  pregnant  uterus  in  the  great  majority   of  cases 

1  The  term  "  procidentia"  is  used  when  the  cervix  descends  outside  the  vulva. 


5o6 


The  Practice  of   Midwifery. 


arises  out  of  prolapse  existing  before  pregnancy.  In  very  rare 
instances,  however,  prolapse  may  be  produced  suddenly  within 
the  first  two  or  three  months  of  pregnancy  by  a  fall  or  violent 
strain,  just  as  it  may  in  the  case  of  the  unimpregnated  uterus. 
When  a  prolapsed  uterus  becomes  pregnant,  the  descent  may  at 
first  be  increased  in  consequence  of  the  increased  weight.  It  has 
already  been  explained  that  descent  is  almost  always  associated 
with  some  degree  of  retroversion  or  retroflexion.  The  case  now  to 
be  considered  is  that  in  which  the  descent  is  the  main  element  of 
the  displacement.  If  the  case  has  been  before  pregnancy  one  of 
prolapse  of  the  second  degree  (called  also  procidentia) ,  in  which  the 
cervix  descends  outside  the  vulva,  but  the  fundus  uteri  remains 

within  the  body,  it  will  almost 
certainly  have  been  associated 
with  more  or  less  elongation  of 
the  supra-vaginal  cervix,  the 
result  of  tension  (Fig.  273). 
During  the  first  two  or  three 
months  of  pregnancy,  the  cervix 
may  still  come  down  outside,  the 
fundus  remaining  in  the  pelvis 
more  or  less  retroverted  or 
retroflexed.  The  congestion  and 
strangulation  of  the  cervix  will 
then  be  greater  than  usual  in 
consequence  of  the  hypersemia 
of  pregnancy.  As  pregnancy 
goes  on,  the  fundus  almost 
always  rises  up  out  of  the 
pelvis,  and  draws  up  the  cervix  after  it.  Hence  in  the  later 
months  of  pregnancy,  although  the  cervix  may  be  lower  than 
usual  in  consequence  of  its  elongation,  it  hardly  ever  comes  out- 
side. Earely  the  fundus  becomes  detained  beneath  the  promontory 
of  the  sacrum,  the  retroflexion  increases  as  pregnancy  goes  on,  and 
the  case  becomes  essentially  one  of  retroflexion  of  the  gravid 
uterus. 

When  the  prolapse  is  mainly  apparent,  and  not  real,  the  con- 
dition is  generally  one  of  hypertrophic  elongation,  not  solely  or 
mainly  of  the  supra-vaginal,  but  of  the  intra-vaginal  portion  of  the 
cervix.  This  also  arises  out  of  a  similar  condition  existing  before 
pregnancy.  There  is  then  usually  some  descent  in  addition,  which 
is  due  to  the  weight  of  the  enlarged  cervix,  and  allows  the  cervix  to 
be  protruded  externally.     As  the  uterus  rises  out  of  the  pelvis,  any 


Fig.  27i. — Prolapse  of  third  degree  in 
unimpregnated  uterus. 


Abnormalities  of  the   Uterus.  507 

descent  of  the  body  of  the  uterus  is  remedied,  and  there  is  a 
tendency  also  to  draw  the  cervix  upward.  But  sometimes  the  cervix 
itself  is  more  or  less  constantly  gripped  and  retained  outside  the 
vulva,  and  then  the  traction  increases  the  elongation  of  the  cervix 
instead  of  remedying  its  malposition.  Its  hypertrophy  also  is 
increased,  in  consequence  of  the  hypersemia  of  pregnancy.  Almost 
all  cases  in  which  the  cervix  uteri  appears  externally  in  the  later 
months  of  pregnancy  after  the  fifth  month  are  to  be  explained 
in  this  way. 

It  is  possible  for  early  pregnancy  to  exist  with  Ti^rolapse  of  the 
third  degree,  in  which  not  merely  the  cervix,  but  the  whole  uterus, 
is  outside  the  body  in  a  position  of  retroflexion  (Fig.  274). 

The  enlarging  mass  then  soon  becomes  strangulated  by  the 
vulva,  and  abortion  follows  if  the  uterus  is  not  reduced.  Cases 
have  been  reported  in  which  this  state  of  things  has  been  supposed 
to  continue  as  long  as  the  fifth  or  even  the  sixth  month.  But 
it  is  probable  that  in  these  cases  the  fundus  was  really  in  the 
pelvis,  inside  the  vulva  (as  in  Fig.  273,  p.  505),  although  the 
vagina  may  have  been  completely  inverted  over  the  procident 
cervix. 

Apparent  prolapse,  due  to  hyperplasia  of  the  cervix,  may  lead 
to  obstruction  in  labour  in  consequence  of  the  difficulty  in  the 
dilatation  of  the  elongated  and  hypertrophied  cervix.  This  will  be 
considered  hereafter. 

Prolapse  of  the  vagina  alone  commonly  affects  the  anterior  wall 
only.  The  posterior  wall  may  also  be  prolapsed  either  with  or 
without  the  anterior  wall,  generally  after  damage  to  the  perineum 
in  former  deliveries.  Prolapse  of  the  anterior  wall  is  often  a 
sequel  of  an  original  prolapse  both  of  uterus  and  anterior  vaginal 
wall,  after  the  uterus  has  been  drawn  up,  owing  to  its  increased 
size.  The  evolution  of  the  vaginal  walls  in  pregnancy  tends  to 
aggravate  the  condition.  In  labour  the  prolapsed  vaginal  wall, 
driven  before  the  head,  may  become  swollen,  and  form  an  obstacle 
to  progress.  It  may  even  slough  from  the  effect  of  prolonged 
pressure. 

Symptoms. — The  symptoms  of  prolapse  in  the  unimpregnated 
state  are  generally  increased  in  the  early  months  of  pregnancy, 
in  consequence  of  the  increased  weight  and  congestion.  Irrita- 
bility of  bladder,  from  the  accompanying  cystocele,  is  often 
troublesome.  If  the  cervix  remains  external  it  is  apt  to  become 
deeply  congested,  irritated,  inflamed,  or  ulcerated  from  friction. 
This  condition  of  the  cervix  may  lead  to  abortion.  A  prolapsed 
vagina  may  become  much  swollen  in  labour,  and  form  an  obstacle 


5o8  The  Practice  of   Midwifery. 

to  the  advance  of  the  head.  In  general,  after  the  fourth  month,  as 
the  cervix  is  drawn  upward  by  the  enlarging  uterus,  the  symptoms 
of  prolapse  are  considerably  relieved,  except  in  those  cases  of 
elongation  of  the  vaginal  cervix,  in  which  the  os  may  remain 
external  to  the  vulva. 

Treatment. — If  there  is  any  notable  prolapse  of  the  uterus  itself 
within  the  first  few  months  of  pregnancy,  it  should  be  supported 
by  an  elastic  ring,  or  full-sized  Hodge's  pessary.  This  may 
generally  be  removed  about  the  end  of  the  fourth  month.  In 
troublesome  cases,  and  more  especially  if  any  ulceration  of  the 
exposed  cervix  has  been  produced,  rest  in  the  horizontal  position 
is  a  great  aid  to  the  treatment.  If  a  pessary  is  not,  at  first,  readily 
tolerated  on  account  of  tenderness  of  the  uterus  or  vagina,  the 
uterus  may  be  supported  by  a  tampon  of  absorbent  cotton,  soaked 
in  a  solution  of  alum  thirty  grains,  boric  acid  four  grains,  to  an 
ounce  of  glycerine,  and  having  a  tape  tied  round  it  for  withdrawal. 
This  should  be  changed  every  day.  If  the  cervix  uteri  is  found 
external  to  the  vulva,  its  reduction  must  be  the  first  step  in  treat- 
ment. In  reducing  it,  care  should  be  taken  not  to  convert  the 
prolapse  into  a  retroflexion  by  pushing  up  the  cervix  only,  and 
leaving  the  fundus  low  down  in  the  hollow  of  the  sacrum.  The 
fundus  should  first  be  pushed  up  from  the  posterior  cul-de-sac  of 
the  vagina,  or  from  the  rectum.  If  there  is  any  difficulty  in  doing 
this,  the  semi-prone,  or  the  knee-elbow  position  will  often  facilitate 
it,  as  described  for  the  case  of  retroflexion  of  the  gravid  uterus 
(see  p.  504). 

Prolapse  of  the  anterior  vaginal  wall  in  the  early  months  is  apt  to 
be  associated  with  some  descent  of  the  uterus,  and  may  then  call 
for  the  use  of  a  pessary.  In  the  later  months  it  is  to  be  treated 
chiefly  by  rest  and  mild  astringents  in  the  form  of  lotion,  or  dis- 
solved in  glycerine  and  applied  by  tampon,  which  may  be  kept  in 
place,  if  necessary,  by  a  perineal  band.  Sometimes,  even  at  this 
stage,  a  large  elastic  ring  pessary  is  of  use,  its  anterior  portion 
holding  up  the  vaginal  wall  behind  the  pubes.  In  labour,  if  the 
prolapsed  and  swollen  vagina  wall  is  driven  down  in  advance  of  the 
head,  it  should  be  gradually  drawn  back  over  it  by  the  fingers.  In 
prolapse  of  the  posterior  vaginal  wall,  pessaries  are  not  generally  of 
service,  and  the  treatment  must  be  confined  to  rest  and  the  use  of 
astringents. 

Apparent  prolapse,  due  to  elongation  of  the  vaginal  cervix,  can 
receive  benefit  from  a  pessary  only  when  it  is  associated  with  some 
actual  descent  of  the  uterus,  as  may  be  the  case  in  the  early  months. 
In  the  later  months  all  that   can  be  done  is  to  prescribe  rest  and 


Abnormalities  of  the   Uterus.  509 

prevent  irritation  of  the  cervix  by  friction.  The  treatment  of 
difficulty  in  parturition,  arising  from  the  hypertrophied  cervix,  will 
be  considered  hereafter.  In  all  cases  of  prolapse,  of  whatever 
variety,  attention  should  be  paid  to  the  regulation  of  the  bowels, 
that  the  displacement  may  not  be  aggravated  by  straining. 

Hernia  of  the  Uterus. — In  the  later  months  the  fundus  uteri 
may  protrude  into  the  sac  of  an  umbilical  hernia  if  greatly  distended, 
or  into  a  ventral  hernia,  due  to  stretching  of  the  cicatrix  of  an 
abdominal  section,  especially  one  in  which  a  pedicle  of  uterine  or 
ovarian  tumour  has  been  fixed.  A  sort  of  hernia  may  also  arise 
simply  from  separation  of  the  recti  muscles.  In  these  cases  the  use 
of  an  abdominal  belt  during  pregnancy  is  sufficient  treatment,  and 
birth  generally  takes  place  naturally  or  with  the  aid  of  forceps. 

In  a  case  recorded  by  Eosner^  the  gravid  uterus  was  incarcerated 
in  a  ventral  hernia,  and  Cesarean  section  followed  by  removal  of  the 
uterus  was  performed. 

In  very  rare  cases  the  uterus  has  been  found  in  the  sac  of  an 
inguinal  or  femoral  hernia,  and  in  still  rarer  pregnancy  has  occurred 
in  such  a  uterus.^  The  diagnosis  would  be  made  by  recognising 
the  characters  of  the  pregnant  uterus  in  the  sac,  the  absence  of  the 
uterus  from  its  usual  position,  and  the  displacement  of  cervix  and 
vagina  towards  the  sac.  Such  cases  have  generally  ended  in  spon- 
taneous abortion.  If  the  uterus  cannot  be  returned,  abortion  should 
be  induced  in  the  early  months  by  passing  a  sound  or  stylet  through 
the  OS.  Later,  an  operation  as  for  strangulated  hernia  may  possibly 
become  necessary.  If  possible  the  uterus  should  not  be  incised,  but 
returned  after  incision  of  the  neck  of  the  sac,  either  with  or  without 
evacuation  of  the  liquor  amnii.  If  this  prove  impossible  the  uterus 
must  be  emptied  and  returned,  or  if  any  signs  of  sepsis  are  present 
hysterectomy  should  be  performed. 

1  Rosner,  Zentralbl.  f.  Gynak.,  1904,  No.  48,  p.  1486. 

2  Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  2nd  ed.,  English  translatioD,  1887,  Vol.  I., 
p,  382, 


Chapter    XXIL 
DISEASES  OF  DECIDUA  AND  OVUM. 

Decidual  Endometritis. — Inflammation  of  the  decidua  arising 
from  endometritis  existing  before  pregnancy  may  or  may  not  be 
associated  with  the  presence  of  organisms  in  the  affected  tissues. 
In  the  latter  case  it  may  be  due  to  gonorrhoea,  tubercle,  syphilis,  or 
to  any  of  the  septic  or  saprophytic  organisms.  The  inflammation 
may  affect  the  decidua  vera,  basalis,  or  capsularis,  or  any  one  or  two 
of  these  divisions.  The  whole  of  the  mucous  membrane  may  be 
involved,  or  only  portions,  leading  to  the  development  of  the  special 
variety  known  as  endometritis  polyposa.  On  microscopical 
examination  are  found  enlargement  of  the  decidual  cells,  infiltration 
of  the  tissues  with  collections  of  small  round  cells,  and  hypertrophy 
and  hyperplasia  of  the  glands.  In  the  most  marked  forms 
haemorrhages  may  occur,  and  may  be  the  exciting  causes  of  an 
abortion.  In  some  cases,  more  especially  in  those  due  to  the  action 
of  various  organisms,  marked  degenerative  changes  occur  in  the 
deciduae.  The  fibrin  layer  of  Nitabuch  is  well  marked,  and  local 
areas  of  necrosis  occur  which  are  composed  mainly  of  degenerate 
decidual  cells.  Another  characteristic  feature  is  the  occurrence  of 
thrombosis  in  the  sinuses  of  the  decidua  basalis  which  contain 
masses  of  large  well-staining  cells,  "  syncytial  wander  cells," 
derived  from  the  syncytium  of  the  chorionic  villi.-^ 

Ultimately  there  may  be  an  excessive  formation  of  connective 
tissue  leading  to  abnormal  attachment  of  the  decidua  to  the 
uterine  wall,  interfering  with  the  formation  of  the  ampullary  layer, 
and  so  causing  adhesions  of  the  placenta  to  the  uterus,  a  condition 
which  is  apt  to  occur  in  successive  pregnancies.  In  a  later  stage 
atrophic  changes  may  also  be  met  with,  the  glandular  layer  then  is 
absent  altogether,  only  a  few  remains  of  the  decidua  basalis  being 
found,  and  the  chorionic  villi,  surrounded  by  some  fibrous  connective 
tissue,become  attached  directly  to  the  m uscle  tissue.  The  muscle  tissue, 
often  thinner  than  normal,  takes  the  place  of  the  decidua  basalis,  and 
Nitabuch's  fibrin  layer  is  formed  in  it,  and  numerous  syncytial 
wander  cells  are  seen  scattered  among  the   muscle   fibres.     The 

1  V.  Franque,  Zeitsch.  f.  Geb.  u.  Gyn.,  1897,  Bd.  37,  no.  11,  s.  277. 


Diseases  of   Decidua  and  Ovum.  511 

causation  of  this  condition  has  been  attributed  to  acute  inflammation 
in  the  puerperium  or  a  previous  chronic  interstitial  endometritis. 

Endometritis  affecting  the  decidua  basalis  is  of  course  the  most 
important  as  regards  its  influence  on  the  life  of  the  ovum.  A  con- 
siderable amount  of  change  in  the  decidua  vera  is  not  incompatible 
with  the  continuance  of  pregnancy,  but  it  may  excite  the  uterus  to 
expel  the  ovum,  especially  when  hsemorrhage  has  occurred  into  the 
tissue. 

To  a  special  form  of  endometritis,  affecting  chiefly  the  decidua 
vera,  but  sometimes  also  the  decidua  capsularis,  the  term  endometritis 
decidualis  tuberosa,  or  endometritis  decidualis  j^olyposa,  has  been 
given.  In  this  the  free  surface  of  the  decidua  becomes  elevated  in 
the  form  of  bosses,  or  polypoid  projections.  These  are  due  chiefly 
to  local  proliferation  of  cells  and  fibroid  tissue,  but  the  swelling 
may  be  increased  by  infiltration  of  blood  into  the  tissue.  Over  the 
bosses,  or  polypoid  projections,  the  orifices  of  the  glands  are 
generally  obliterated  by  the  cell-growths,  but  in  the  intervening 
parts  of  the  decidua  they  remain  visible. 

Symptoms. — Pain  referred  to  the  uterus,  or  tenderness  of  the 
uterine  walls  during  pregnancy,  may  arise  from  endometritis 
decidualis,  but  symptoms  may  be  altogether  absent. 

Catarrhal  Decidual  Endometritis  or  Hydrorrhoea  gravidarum. — In 
some  cases  a  discharge  takes  place  during  pregnancy  of  a  thin 
watery  or  muco-purulent  fluid.  This  may  begin  in  the  third  or 
fourth  month,  but  is  more  abundant  in  the  later  months  of  preg- 
nancy. It  is  attributed  to  hypertrophy  of  the  glands  of  the  decidua, 
persistence  of  the  ducts,  and  excessive  secretion  from  them.  Small 
cysts  may  be  present  forming  the  so-called  endometritis  cystica. 
Sometimes  the  discharge  takes  place  continuously,  or  frequently  in 
small  quantities.  In  other  cases,  if  its  exit  is  obstructed  by  a  plug 
of  tenacious  mucus  in  the  os,  or  adhesion  between  the  decidua  vera 
and  reflexa,  it  may  be  retained  until  a  considerable  quantity  is 
accumulated,  and  then  be  discharged  in  a  sudden  gush.  Such  a 
flow  is  liable  to  be  mistaken  for  the  escape  of  the  liquor  amnii,  or  of 
the  fluid  which  sometimes  collects  between  the  amnion  and  chorion. 
From  both  of  these  it  is  distinguished  by  the  fact  that  the  discharge 
generally  takes  place  more  than  once,  and  from  escape  of  the  liquor 
amnii  by  the  fact  that  pregnancy  continues  uninterrupted.  In 
some  cases,  however,  uterine  action  may  be  set  up,  and  premature 
labour  follow.  Ahlfeld^  has  recorded  a  case  in  which  as  much  as 
500  cc.  was  evacuated.  Paul  Bar  and  others  maintain  that  this 
escape  of  fluid  is  often  really  due  to  the  rupture  of  the  membranes 

I   [lolzapfel,  Hegar's  Beitrage,  1903,  Bd.  8,  s.  1. 


512 


The  Practice  of   Midwifery. 


without  the  supervention  of  labour,  and  Meyer  Euegg  has  collected 
fifteen  cases  in  which  periods  of  fifteen  to  120  days  have  elapsed 
between  the  escape  of  the  liquor  amnii  and  the  occurrence  of  labour. 

In  such  a  case  the  foetus  can  either  continue  to  develop  within  the 
amniotic  cavity  or  may  escape  through  the  tear  and  continue  its 
development  outside  the  membranes,  the  so-called  exochorial 
development  of  the  foetus.  In  the  latter  case  the  membranes 
retract  and  lose  their  elasticity,  the  opening  through  which  the 
foetus  escaped  contracting  round  the  cord.  No  treatment  is  of  any 
avail,  except  the  use  of  sedatives  and  rest  if  premature  labour 
should  appear  to  be  threatened. 

Acute  endometritis  or  acute  metritis  in  pregnancy  may  arise  in  the 
course  of  acute  zymotic  diseases.  Apart  from  such  a  cause  they 
are  hardly  ever  observed  unless  as  the  result  of  some  complication, 
such  as  the  presence  of  a  tumour,  or  the  incarceration  of  a  retro- 
verted  uterus  ;  or,  when  septic,  from  a  traumatic  cause,  such  as  the 
attempt  to  induce  abortion. 

Anomalies  and  Diseases  of  the  Degidua  Basalis  and  Placenta. 


Anomalies  of  Form  and  Size. — The  cord  may  be   attached  to 
the  edge,  instead  of,  as  usual,  near  to  the  centre  of  the  placenta. 

This  variety  is  called  the 
battledore  placenta  (Fig.  275). 
The  cord  may  reach  the 
membranes  a  little  distance 
from  the  edge  of  the  pla- 
centa, the  vessels  dividing 
into  branches  before  arriv- 
ing at  the  placenta,  and  the 
branches  running  in  the 
membranes.  This  consti- 
tutes the  placenta  velamen- 
tosa  (Fig.  289,  p.  535).  It  is 
the  result  of  the  abdominal 
pedicle  having  been  attached 
to  the  decidua  reflexa  instead 
of  the  decidua  serotina.  In 
such  a  case,  the  cord  will  readily  tear  away  from  the  placenta,  if 
any  traction  is  made  upon  it.  In  rare  cases  there  are  detached 
masses  of  placental  tissue  apart  from  the  main  placenta,  and  due  to 
development  of  isolated  patches  of  chorionic  villi.  These  are  called 
placentce  succentiiriatce  (Fig.  276) .    They  are  of  considerable  practical 


Fig.  275. — Battledore  placenta. 


Diseases  of   Decidua  and   Ovum. 


513 


importance,  because  they  may  easily  remain  behind  in  the  uterus 

undetected,  and  give  rise  either  to  secondary  j^ost-partum  heemor- 

rhage   or  to   decomposition   and   septic  absorption.      The  vessels 

supplying  them  may  run  from   the 

edge  of  the  main  placenta,  or  may  be 

separate  branches  in  a  velamentous 

insertion  of   the    funis.     Their   torn 

ends   would   be  the  chief  indication 

of  a  separate  lobe  having  been  left 

behind. 

In  some  instances  the  secondary 
portions  are  so  large  as  to  constitute 
a  placenta  consisting  of  two  equal 
portions,  a  placenta  cliniidiata,  or 
even  a  placenta  tripartita,  or  tliree- 
lobed  placenta.  A  placenta  marginata 
presents  a  grey-white  band  running 
all  round  the  placenta  at  the  margin, 
and  due  to  the  formation  of  a  collar 
of  white  infarction  at  the  junction  of 
the  decidua  reflexa  and  decidua 
basalis.  The  term  placenta  circum- 
vallata  is  applied  to  the  placenta  when  the  chorion  is  folded  over 
at  the  margin,  and  a  collar-like   thickening  is  thus  formed   on 


^-^vlffS- 


FiGr.  276. — Placenta  succenturiata. 


Fig.  277. — Placenta  circumvallata. 


the  fcetal  aspect  with  its  rim  directed  towards  the  centre.  Some- 
times the  placenta  is  thinner  than  usual,  and  spread  over  a  larger 
surface  of  the  uterus.  Such  a  placenta  is  called  placenta 
membranacea.  Both  of  the  last  two  conditions  probably  result 
M.  33 


SH 


The  Practice  of   Midwifery. 


from  a  reflexal  development  of  placenta  (see  Chapter  XXV.). 
This  again  may  be  the  consequence  of  the  imperfect  development 
of  the  normal  part  of  the  placenta,  due  to  previous  endometritis. 
In  other  cases  there  appears  to  be  actually  excessive  development 
of  the  placenta.  Sometimes  this  is  associated  with  an  excessively 
large  fcetus,  sometimes  with  hydrops  amnii.  Sometimes  also  it 
api^ears  to  be  a  kind  of  comj)ensatory  hypertrophy,  when,  for  some 
reason,  the  fcetus  has  a  difficulty  in  obtaining  nutriment  enough. 
The  j)lacenta  sometimes  appears  to  be  unusually  small,  without  any 
obvious  ill  effect  upon  the  fcetus.  It  has  already  been  mentioned 
that   in   multiple   pregnancy,    if   one    or  more   placentae   are  less 


Fig.  278. — Blighted  ovum  with  irregular  thickening  of  membranes. 

favourably  placed,  or  insufficient  in  extent,  the  corresponding  foetus 
is  apt  to  perish. 


Congestion  of  the  Placenta  and  Placentitis. — Congestion  of 
the  decidua  basalis  and  maternal  portion  of  the  placenta  may 
arise  from  j)assive  obstruction  in  the  maternal  vascular  system,  as, 
for  instance,  from  cardiac  or  renal  disease,  or  it  may  be  the  result 
of  inflammation  of  the  endometrium.  In  either  case  it  may  lead 
to  haemorrhage,  and  formation  of  thrombus,  and  this  may  cause  the 
death  of  the  embryo,  or  excite  the  uterus  to  expel  the  ovum.  In 
the  fully  formed  placenta,  permeated  by  the  maternal  blood  spaces, 
congestion  on  the  maternal  side  can  exist  only  in  the  form  of 
excessive  blood  pressure.      This  also  may  lead  to  the  formation  of 


Diseases  of   Decidua  and  Ovum.  515 

thrombus,  for  if  the  blood  escapes  into  any  space  which  it  does  not 
naturally  occupy,  and  in  which  the  current  stagnates,  clotting  takes 
place. 

The  study  of  inflammation  in  the  placenta  is  a  difficult  one,  and 
much  that  has  been  written  upon  the  subject  is  erroneous.  Inflam- 
mation may  occur  in  the  decidua  basalis  and  maternal  portion  of 
the  placenta,  as  well  as  in  the  decidua  vera  and  capsularis. 

Thrombosis  in  the  maternal  blood  spaces  of  the  incipient 
placenta  is  also  apt  to  be  produced,  and  is  attributed  to  primary 
thrombosis  in  the  sinuses  of  the  decidua  basalis  or  uterus.-^  The 
blood  spaces  become  distended,  and  elevated  into  irregular  pro- 
tuberances on  the  foetal  surface  of  the  placenta,  formed  by  clot. 
The  embryo  perishes  in  consequence,  and  remains  very  small  in 
proportion  to  the  size  of  the  placenta  (Fig.  278). 

Infarcts. — The  commonest  abnormality  seen  in  the  placenta  con- 
sists of  white  infarcts.  These  form  generally  conical  whitish  or 
yellowish  firm  masses,  with  the  base  of  the  cone  on  the  maternal 
surface  of  the  placenta,  and  result  from  obliteration  of  a  branch  of 
a  chorionic  artery.  Microscopic  infarcts  are  present  in  all 
placentae  at  full  term,  and  have  been  well  described  by  Whifcridge 
Williams.^ 

If  they  are  unusually  numerous  or  large  they  indicate  premature 
degenerative  changes  and  senility  of  the  placenta  and  are  of 
importance.  The  primary  change  is  obliterative  endarteritis  in 
one  of  the  arteries  of  a  villus,  leading  to  coagulation  necrosis 
affecting  the  cells  of  Langhans'  layer  and  then  those  of  the 
syncytium.  This  is  followed  by  the  clotting  of  the  maternal  blood 
in  contact  with  the  villus,  death  of  the  tissues  of  the  latter,  and  the 
formation  of  a  homogeneous  whitish  or  yellowish  mass,  the  white 
infarct.  In  this  the  remains  of  the  villi,  more  or  less  degenerated, 
can  be  recognised. 

Eed  infarcts  are  less  commonly  seen,  and  occur  most  frequently 
on  the  maternal  surface  of  the  placenta.  Their  frequent  association 
with  chronic  nephritis  and  death  of  the  fcetus  renders  them  of 
importance  clinically. 

It  is  possible  that  in  some  cases  the  formation  of  infarcts  may  be 
the  result  of  inflammation  of  the  maternal  tissues  spreading  to  the 
cells  of  the  villi. 

For  the  majority  of  infarcts,  and  especially  for  those  occurring  in 

1  See  Bcny  ilart, -''J'tiberose  J<'le.sliy  Mole,"  Jouin.  of  Obst.  luid  Gyn.,  May,  1902, 
Vol.  I.,  p.  479. 

2  Whitridge  Winiams,  Arner.  Jouin.  Obst.,  1900,  Vol.  XLI.,  pp.  775—801. 

38—2 


5i6 


The   Practice  of   Midwifery. 


the  decidua  basalis  and  the  intervillous  spaces,  the  cause  is  to  be 
found  in  inflammatory  changes  in  the  decidua,  while  those 
primarily  of  chorionic  origin  and  arising  mainly  in  the  last  months 
of  pregnancy  no  doubt  are  secondary  to  atrophy  and  shedding  of  the 
epithelium  of  the  chorionic  villi. 

Calcification. — In  many  cases  calcareous  deposits  are  found  on 
the  maternal  surface  of  the  placenta  in  the  decidua  basalis.  They 
appear  to  be  due  in  general  to  calcification  occurring  in  infarcts 


d^ 


■^ 


Fig.  279. — Villi  from  specimen  of  syphilitic  placenta.  The  enlargement  of 
the  villi,  the  degenerative  changes  in  the  stroma,  and  the  obliteration  of 
some  of  the  vessels  of  the  villi  are  shovs^n. 

and  old  clots,  are  often  associated  with  adhesion  of  the  placenta,  and 
are  indicative  of  old  age  and  degeneration.  Calcareous  deposits  in 
the  foetal  tissues  in  proliferating  and  degenerating  areas  of  the 
adventitia  of  the  chorionic  vessels  have  also  been  described. 


Syphilis  of  the  Placenta. — The  most  characteristic  change  in 
the  syphilitic  placenta  is  its  increase  in  weight  relatively  to  that  of 
the  fcetus.  Thus  the  relation  between  the  weight  of  the  two  is  often 
1 — 3  in  place  of  the  normal  1 — 55.  The  placenta  is  jDale  and 
mottled  with  yellowish-white  patches,  its  consistence  is  often  soft 
and  friable,  while  the  cord  may  be  oedematous,  and  the  amount  of 
liquor   amnii  is  often  excessive.     Examination   of  the   teased-out 


Diseases  of   Decidua  and   Ovum.  517 

chorionic  villi  shows  even  to  the  naked  eye  that  they  are  shorter 
and  thicker  than  in  the  normal  placenta.  Under  the  microscope  it 
can  be  seen  that  the  villi  are  increased  in  size  and  are  placed  more 
closely  together,  the  intervillous  spaces  being  to  a  large  extent 
obliterated.  The  stroma  of  the  villi  contains  a  very  large  number 
of  round  cells,  and  the  vessels  present  evidence  of  periarteritis  and 
endarteritis,  leading  in  some  instances  to  their  complete  occlusion, 
with  consequent  degeneration  of  the  stroma  (see  Fig.  279).  Here 
and  there  proliferation  of  the  cells  of  the  syncytium  on  the  surface 
of  the  villi  is  taking  place,  and  owing  to  the  manner  in  which  the 
villi  are  packed  together,  ifc  appears  in  places  as  if  there  was 
actually  inclusion  of  syncytial  cells  in  the  stroma  of  the  villi. 
Gummata  occasionally,  but  rarely,  occur.  The  spirochseta  pallida 
can  be  demonstrated  readily  in  the  villi,  but  are  rarely  found  in  the 
maternal  decidua. 

Tubercle  of  the  placenta  has  been  observed  in  conjunction  with 
phthisis  of  the  mother,  but  is  very  rare. 

No  doubt  most  of  these  cases  begin  as  a  tuberculous  endometritis 
from  which  the  intervillous  spaces  are  infected  secondarily,  with 
subsequent  destruction  of  the  epithelium  of  the  villi,  opening  up  of 
the  blood-vessels,  and  finally  invasion  of  the  fcetal  blood  by  tubercle 
bacilli.  Cases  have  been  described  in  which  the  primary  site 
appeared  to  be  the  chorionic  villi.-"^ 

Tumours  of  the  Placenta.— All  tumours  of  the  placenta  are 
in  reality  derived  from  the  chorionic  villi,  and  almost  all  have  the 
structure  of  chorioangiomata.  They  are  of  very  rare  occurrence 
and  are  usually  single.  The  tumours  are  covered  on  the  surface 
with  a  layer  of  epithelium  derived  from  the  cells  of  Langhans'  layer 
or  the  syncytium,  and  beneath  this  there  is  a  thin  connective  tissue. 
The  interior  of  the  tumour  is  made  up  almost  entirely  of  a  number 
of  dilated  vessels  derived  from  the  vessels  of  the  villi  and  set  in  a 
sparse  connective  tissue  stroma.  Tumours  of  a  fibrous  or  fibro- 
myxomatous  structure,  in  continuity  with  the  chorionic  villi,  have 
also  been  observed. 

Cysts  of  the  placenta  are  sometimes  seen,  usually  on  the  foetal 
surface  of  the  placenta  near  the  centre.  They  are  most  frequently 
formed  by  cystic  degeneration  of  the  cells  of  Langhans'  layer,  but 
may  occur  in  old  infarcts  or  blood  clots. 

1  Schmoii  and  Kockel.  Zioglers  Beitriigc  z.  Path.  Auat.,  1891,  Bd.  10,  lift.  2, 
s.  313. 


5i8  The   Practice  of   Midwifery. 

CEdema  of  the  Placenta.— In  some  cases  the  placenta  is  found 
unusually  large,  heavy,  pale  in  appearance  ;  and  the  fluid  which 
oozes  from  it  is  not  pure  blood,  but  semi- serous  in  character.  The 
placenta  still  remains  unusually  large  and  heavy,  even  after  drain- 
ing. There  has  thus  been  actual  hypertrophy  of  the  villi,  in 
compensation  for  the  impairment  of  their  function. 

QEdema  of  the  placenta  may  arise  from  a  fault  either  on  the 
maternal  or  the  fcetal  side.  Thus  it  has  been  observed  in  con- 
junction with  general  oedema  from  albuminuria,  or  with  ascites 
arising  from  hepatic  obstruction  on  the  mother's  part.      In  other 


Fig.  280.— Tuberous  fleshy  mole,  blood  being  effused  in  masses  under  the 
foetal  surface  of  the  membranes. 

cases,  it  is  associated  with  hydramnios  or  oedema  of  the  foetus,  and 
then  appears  to  be  dependent  on  some  anomaly  causing  obstruc- 
tion in  the  foetal  circulation.  The  blood  circulating  in  the  maternal 
blood  spaces  may  also  be  too  watery,  if  the  cause  of  the  affection 
is  albuminuria  or  anaemia  on  the  mother's  side.  (Edema  of  the 
placenta  is  apt  to  lead  to  imperfect  development  or  death  of  the 
foetus,  and  to  premature  labour. 

Thrombosis  :  Carneous  Mole  or  Blood  Mole — Thrombosis 
of  the  placenta,  leading  to  distension  of  portions  of  the  maternal 
blood  space  with  clot,  may  result  either  from  inflammation  or 
degeneration  of  the  maternal  or  foetal  portions  of  the  placenta  and 


Diseases  of   Decidua  and  Ovum. 


519 


especially  from  thrombosis  of  the  maternal  vessels  (see  p.  515).  It 
may  also  arise  from  partial  detachment  of  the  chorion  or  placenta 
from  the  uterine  wall  as  the  result  of  uterine  contractions  set  up 
by  violence,  emotion,  or  other  exciting  cause  of  abortion.  This 
is  apt  to  lead  to  the  death  of  the  embryo,  which  may  entirely 
disappear  if  it  has  only  advanced  to  a  very  early  stage  of  develop- 
ment, or  may  remain  of  very  small  size  in  comparison  to  the  size 
of  the  whole  ovum  (Fig.  280).  The  amnial  cavity  may  then  shrink 
up,  or  the  amnion  may  be  ruptured  from  the  increased  pressure, 
and  the  liquor  amnii  escape.  The  foetal  and  maternal  membranes, 
infiltrated  with  clotted  blood,  or  having  isolated  masses  of  clot  in 
their  substance,  then  form  a  firm, 
fleshy  mass,  called  a  carneous  ov  fleshy 
mole.  This  may  be  retained  in  the 
uterus  for  some  weeks  or  months, 
but  is  eventually  expelled,  usually 
not  later  than  the  fifth  month.  In 
other  cases,  the  amnial  cavity 
remains  patent,  though  the  main 
part  of  the  mass  retained  in  utero  is 
formed  by  the  thickened  membranes 
(Fig.  281).  The  term  "mole"  (from 
mold,  a  shapeless  mass)  is  properly 
applicable  only  where  there  is  no 
embryo.  But  it  is  often  applied  to 
an  ovum  with  thickened  infiltrated 
membranes,  even  though  an  amnial 
cavity  and  small  embryo  may  be 
present,  as  in  Figs.  280,  281. 

The  situation  where  blood  is  effused  may  be  in  the  substance 
of  the  chorion  or  decidua,  or  between  them  and  the  uterine  wall, 
into  the  chorio-decidual  space.  Frequently  clot  is  found  partly 
infiltrated  among  the  villi,  and  partly  in  rounded  masses  under  the 
chorion  and  amnion,  which  form  prominences  toward  the  amnial 
cavity  (Fig.  280,  the  tuberous  fleshy  mole  of  Berry  Hart^).  Another 
frequent  situation  for  blood  to  be  effused,  and  to  form  clots,  is 
the  decidual  cavity.  It  rarely  breaks  through  into  the  amnial 
cavity. 

The  firm  substance  eventually  expelled  may  have,  at  first  sight, 
very  little  resemblance  to  an  ordinary  ovum.  Not  only  may  an 
early  embryo  have  Ijeen  dissolved,  and  the  liquor  amnii  absorbed, 
Ijut  the  amnion  may  have  been  ruptured,  from  the  pressure  of  the 

'   I'.eriy  Ilmt,  Journ.   (Jbst.  uiid  Cyii.  I'.iit.  Kmp.,  May,  1!J02,  Vol.  I.,  p.  479. 


Fig.  281. — Blighted  ovum,  showing 
morbid  enlargement  of  the 
umbilical  cord. 


520 


The  Practice  of   Midwifery. 


Fig.  282. — Section  of  placental  tissue  from  an  early  ovum  retained  four  months 
in  utero  after  death  of  embryo,  r,  villus  ;  si',  syncytium  covering  villus  ; 
sj),  syncytium  proliferating  in  branching  processes.  x  120.  (From  a 
photograph.) 


Fig.  283. — A  portion  of  the  section  shown  in  Fig.  282  more  highly  magnified.      The 
letters  signify  the  same  as  in  Fig.  282.      x  2i0.     (From  a  photograph.) 


Diseases  of   Decidua  and  Ovum.  521 

extravasation,  or  as  a  result  of  an  early  hydramnion,  and  the 
embryo  may  have  escaped  unobserved.  The  chorionic  villi,  retain- 
ing their  attachment  to  the  uterus,  may  continue  to  grow  to  some 
extent,  so  that  their  bulk  is  large  in  comparison  with  the  embryo, 
if  this  can  still  be  detected,  A  large  portion  of  the  mass,  however, 
generally  consists  of  compressed  clot,  which  may  have  become 
decolorised.  The  nature  of  the  carneous  mole  may  always  be 
determined  by  recognition  of  the  chorionic  villi  on  microscopic 
examination.  They  can  generally  be  seen  most  easily  if  a  small 
portion  of  the  mass  is  teased  out  on  a  slide  and  examined  with  a 
low  power.  They  may,  however,  also  be  seen  in  section,  generally 
embedded  in  the  midst  of  fibrin,  if  sections  be  cut  of  the  whole 
mass.  When  a  section  is  examined  in  this  way  it  is  often  evident 
that  there  has  been,  relatively,  excessive  proliferation  of  the 
cellular  substance  of  the  chorion,  with  deficient  development  of  its 
vessels. 

Blighted  Ovum. — In  other  cases,  again,  the  embryo  perishes  from 
some  cause  or  other,  whether  this  be  some  morbid  condition  in 
itself,  the  funis  (see  Fig.  281),  the  membranes  (see  Fig.  280,  p.  518), 
or  the  maternal  organism.  The  blighted  ovum  with  relatively 
slight,  or  without  any,  thickening  of  the  membranes,  may  then 
sometimes  be  retained  in  a  similar  way  for  weeks  or  even  months 
before  it  is  expelled.  Generally  it  is  expelled  after  two  or  three 
months  at  the  outside ;  but  in  some  cases  it  has  been  retained  up 
to  what  would  have  been  the  full  term  of  pregnancy,  and  then 
expelled.  The  term  missed  abortion  is  sometimes  applied  to  such 
retention  of  a  dead  ovum,  on  the  analogy  of  "  missed  labour,"  the 
term  used  when  a  dead  fcetus  is  retained  in  the  uterus  after  full 
term.  In  general  the  microscopic  appearance  of  a  section  of 
carneous  mole  or  blighted  ovum  shows  more  or  less  degenerated 
villi,  mixed  up  with  clot.  In  some  cases,  however,  a  vegetative  life 
appears  to  continue  for  weeks  or  months,  associated  even  with 
active  proliferation  of  the  syncytium  covering  the  villi,  as  shown 
in  Figs.  282,  283.  In  this  way  the  absence  of  decomposition, 
even  after  the  ovum  has  been  broken  up  for  a  long  time,  is 
accounted  for. 

While  there  is  no  doubt  that  chorionic  villi  may  remain  per- 
fectly fresh  in  appearance  and  free  from  decomposition  for  weeks 
after  the  death  of  the  embryo,  while  in  contact  with  maternal 
blood,  it  has  been  a  disputed  point  whether  they  can  continue  to 
grow  under  these  circumstances.  There  seems  to  be  no  reason, 
however,  why  they  should  not  be  nourished  by  the  maternal  blood, 
without  any  footal  circulation  through  them ;  and,  in  hydatidiform 


522  The  Practice  of   Midwifery. 

degeneration,  there  is  no  doubt  that  they  are  so  nourished.  In 
favour  of  the  view  that  chorionic  tissue  may  grow  after  death  of  the 
embryo  is  the  fact  that,  in  a  bhghted  ovum,  there  is  often  found  a 
relatively  considerable  mass  of  placental  tissue  with  a  very  minute 
embryo  (see  Figs.  278,  280),  or  without  any  embryo  in  the  closed 
amuial  cavity.  And  the  appearance  of  active  proliferation  of  the 
syncytium  four  months  after  death  of  the  embryo,  shown  in 
Figs.   282,  283,  appears  to  amount  to  a  demonstration. 

Symptoms  and  Diagnosis  of  Carneous  Mole  or  Blighted  Ovum. — 
When  the  ovum  has  perished,  the  general  signs  of  pregnancy, 
especially  the  evolution  of  the  breasts,  subside.  Vomiting  of  preg- 
nancy is  also  frequently  arrested  or  diminished.  When  the  liquor 
amnii  has  escaped  or  been  absorbed,  and  a  carneous  mole  has  been 
formed,  examination  of  the  uterus  bimanually  may  show  it  to  be 
firmer  than  is  usual  in  pregnancy,  on  account  of  the  more  solid 
character  of  its  contents.  It  must  be  remembered,  however,  that 
firmness,  as  detected  at  any  particular  moment,  may  be  due  to 
contraction  of  the  uterus,  and  not  to  solid  material  within  it. 
When  the  embryo  has  been  dead  for  some  time,  the  size  of  the 
uterus  will  be  less  than  it  should  be  in  accordance  with  the  date  of 
pregnancy,  and  the  size  remains  stationary,  instead  of  progressing 
with  the  advance  of  pregnancy.  This  is  the  most  reliable  sign  of 
all ;  and,  in  case  of  doubt  .whether  the  ovum  is  still  alive,  it  is 
desirable,  when  symptoms  are  not  too  serious,  to  wait  until  time 
enough  has  elapsed  for  it  to  be  manifested.  It  should  not  be 
forgotten  that  pregnancy  sometimes  commences  in  a  period  of 
amenorrhoea,  and  that,  on  this  account,  the  jDregnancy  may  be 
supposed  to  be  further  advanced  than  it  really  is.  During  the 
retention  of  the  carneous  mole,  or  blighted  ovum,  there  is  no  proper 
menstruation.  Either  amenorrhoea  may  persist,  or  there  may  be 
a  continuous  or  irregular  sanguineous  discharge.  Sometimes  the 
colour  of  the  discharge,  instead  of  being  that  of  bright  blood,  is 
brownish,  from  the  breaking  up  of  clot. 

Treatment. — In  some  cases  the  retention  of  a  dead  ovum  appears 
not  to  affect  the  health  perceptibly.  The  case  may  then  be  left 
to  nature,  in  the  exjDectation  that  the  contents  of  the  uterus  will 
be  expelled  within  a  few  weeks,  and  delay  is  specially  indicated, 
if  there  be  any  doubt  about  the  diagnosis.  If  there  is  a  general 
appearance  of  cachexia,  or  other  sign  that  the  health  is  suffering, 
if  there  is  haemorrhage  or  offensive  discharge,  or  if  the  retention  is 
long  protracted,  the  uterus  should  be  emptied.  A  few  full  doses  of 
ergot  may  first  be  tried,  and  the  sound  may  be  passed  into  the 
uterus.     If  these  means  do  not  bring  about  expulsion,  the  os  may 


Diseases  of   Decidua  and   Ovum. 


523 


be  dilated  with  a  laminaria  tent.  This  may  be  followed  up,  if 
necessary,  by  dilatation  with  Hegar's  dilators,  under  anaesthesia, 
and  digital  evacuation  of  the  uterus  as  described  in  Chapter  XXIV. 

Hydatidiform  Degeneration  of  the   Chorion.     Vesicular  or 
Hydatidiform  Mole. — In   this   disease  the   villi   of   the   chorion 

undergo  proliferation  with  cystic  degeneration,  so  that  portions 
of  them  become  converted  into  cysts  filled  with  a  fluid  containing 
mucin,  0*29  per  cent.,  as  well  as  albumen,  0'61  per   cent.,  and 


Fig.  284. — Hydatidiform  degeneration 
of  chorion. 


Fig.  285. — Commencement  of  hydati- 
diform degeneration  of  chorion. 


resembling  closely  that  of  a  serous  transudation.  The  vesicles  may 
be  of  any  size  up  to  about  lialf  an  inch,  or  even  more.  The  general 
appearance  produced  is  shown  in  Fig.  284.  It  has  been  compared 
to  that  of  a  bunch  of  grapes,  but  the  mode  of  attachment  of  the 
cysts  is  essentially  different.  Instead  of  being  attached  by  stalks 
to  branches  of  a  main  stem,  each  cyst  is  attached  by  a  pedicle  to 
another  cyst,  that  again  to  another,  and  the  final  pedicle  not  to  a 
main  stem,  but  to  the  convex  surface  of  a  membrane,  the  chorion. 
The  formation  of  the  individual  vesicles  is  due  to  the  fact  that  the 
proliferation  of  cells  with  degeneration  does  not  aftect  the  villi 
uniformly  throughout,  ]mi  takes  place  at  detached  centres  (Fig.  284). 


524 


The  Practice  of   Midwifery. 


The  altered  portion  of  the  villus  grows  into  the  vesicle  ;  the  inter- 
vening parts  which  remain  normal,  or  comparatively  normal,  form 
the  connecting  pedicles. 

The  microscopical  appearances  of  a  hydatidiform  mole  are  as 
follows  :  in  the  small  and  young  cysts  the  stroma  is  composed  of  a 
firbillary  substance  presenting  a  swollen  appearance  and  containing 
some  spindle-shaped  connective  tissue  cells  with  well-preserved  nuclei. 
In  the  larger  cysts  the  ground  substance  has  practically  disappeared, 
and  is  limited  to  a  thin  layer  of  fibrous  tissue  lining  the  covering 
epithelium.     The  homogeneous  mass   replacing  it,  the   result   of 


Fig.  286." 


-Villi  of  mole,  r,     with  proliferation  of   the  walls  of  Langhans' 
layer,  c.l.,  and  some  traces  of  syncytium. i 


dropsical  degeneration  of  the  tissues,  contains  the  remains  of  a  few 
degenerate  cell  masses  and  a  few  leucocytes.  The  blood-vessels 
have  disappeared,  and  their  remains  can  only  be  seen  in  the  stalks 
of  the  cysts. 

Very  characteristic  changes  occur  in  the  epithelium  on  the 
surface,  consisting  of  marked  proliferation  of  the  cells  of  Langhans' 
layer  and  of  the  syncytium  and  of  the  formation  of  vacuolar  spaces 
in  the  masses  of  syncytium. 

The  proliferating  chorionic  epithelium  leads  to  an  almost  total 

1  See  Proc.  Eoy.  Soc.  Med.  London,  March,  1909,  Obstetrical  Section 


Diseases   of   Decidua  and  Ovum.  525 

destruction  of  the  decidua  with  which  it  is  in  contact,  and  collections 
of  separated  syncytial  cells  can  be  recognised  lying  embedded 
among  the  muscle  fibres  or  contained  in  the  vessels  of  the  uterine 
wall  often  weeks  after  the  expulsion  of  the  mole. 

In  the  majority  of  cases,  the  degeneration  commences  within 
the  first  two  months  of  pregnancy,  before  the  placenta  is  fully 
differentiated,  and  it  then  usually  affects  the  whole  of  the  convex 
surface  of  the  chorion.  The  embryo  may  have  disappeared 
altogether,  or  may  be  found  in  a  blighted  condition,  if  it  has 
reached  a  somewhat  later  stage  of  development.  When  the 
hydatidiform  change  commences  after  the  formation  of  the  placenta, 
it  generally  affects  only  the  placental  site.  In  the  great  majority 
of  cases,  the  foetus  perishes  before  or  after  the  formation  of  the 
mole  has  begun,  but  in  some  instances,  in  which  only  a  few 
lobes  of  the  placenta  have  become  degenerated,  or  in  which  the 
degeneration,  though  more  widely  spread,  is  only  partial,  a  healthy 
foetus  has  been  found  in  combination  with  a  vesicular  mole. 

Occasionally  signs  of  commencing  hydatidiform  degeneration 
can  be  recognised  in  the  placenta  of  an  ordinary  early  abortion. 
Not  infrequently  a  twin  foetus  is  associated  with  a  vesicular  mole. 
In  some  cases  the  tendency  to  active  proliferation  of  the  diseased 
villi  is  shown  by  their  invading  the  uterine  wall.  They  appear  to 
reach  the  uterine  sinuses  by  growing  into  them  from  the  maternal 
blood  spaces,  as  the  normal  villi  sometimes  do.  But  they  sometimes 
penetrate  much  more  deeply  into  the  uterine  wall  than  normal  villi 
ever  do,  and  may  reach  quite  close  to  the  peritoneal  surface.  In 
some  cases  the  uterine  wall  becomes  broken  down,  in  consequence 
of  the  pressure  produced  by  their  proliferation ;  the  muscle  fibres 
become  destroyed  and  rarefied  and  replaced  by  the  diseased  mass, 
the  so-called  malignant  mole.  If  this  process  reaches  near  to  the 
outer  surface,  peritonitis  may  be  set  up,  or  even  rupture  of  the 
uterus  may  occur.  This  tendency  to  a  semi-malignant  proliferation 
must  be  associated  with  the  occurrence  of  deciduoma  malignum  so 
far  more  frequently  as  a  sequence  of  vesicular  mole  than  of  an 
ordinary  delivery  or  abortion. 

Occasionally  secondary  metastatic  growths  are  met  with  in  the 
vagina  associated  with  what  appears  to  be  an  ordinary  hydatidiform 
mole  i7i  liter o. 

No  certain  histological  characters  are  at  present  known  by  which 
it  is  possible  to  recognise  a  malignant  mole,  although  the  deep 
penetration  of  the  villi  and  the  presence  of  numerous  masses  of 
syncytial  cells  in  the  muscle  tissue  are  suspicious  characters. 

A  vesicular  mole  sometimes  grows  to  so  great  a  size  as  to  enlarge 


526  The  Practice  of   Midwifery. 

the  uterus  as  much  as  pregnancy  at  full  term.  More  frequently 
the  uterus  is  not  enlarged  beyond  its  size  at  the  fifth  or  sixth 
month  of  pregnancy. 

Causation. — The  causation  of  the  degeneration  is  not  fully 
understood.  The  formation  of  the  vesicular  mole  has  sometimes 
been  repeated  in  the  same  woman,  and  hence  it  is  inferred  that  the 
condition  of  the  mother  may  have  something  to  do  with  it.  Thus 
inflammation  of  the  decidua  may  be  a  predisposing  cause,  and  this 
condition  has  actually  been  found  in  conjunction  with  the  vesicular 
mole.  Again,  Bright's  disease,  ansemia,  or  chlorosis  in  the  mother 
has  appeared,  in  some  instances,  to  be  the  predisposing  cause. 
The  two  main  theories  as  to  its  causation  are  that  it  is  due  to 
some  primary  affection  of  the  ovum  or  that  it  is  due  to  pathological 
changes  in  the  decidua  and  interference  with  its  blood  supply.  If 
some  defect  on  the  part  of  the  ovum  is  the  cause,  it  is  possible  that 
this  may  be  derived  either  from  the  mother  or  from  the  father. 

According  to  some  authorities,  the  frequent  association  of  cysts  of 
the  corpora  lutea  is  an  important  etiological  factor.  They  are 
usually  accompanied  by  an  excessive  formation  and  dissemination 
of  lutein  cells  in  the  stroma  of  the  ovary,  and  those  writers  who 
regard  the  corpus  luteum  as  a  body  with  an  internal  secretion  pre- 
siding over  the  early  nutrition  and  embedding  of  the  ovum  regard 
the  excess  of  lutein  tissue  as  the  cause  of  the  hydatidiform  degene- 
ration. It  is  more  likely,  however,  that  the  same  cause  which  leads 
to  the  proliferation  of  the  chorionic  epithelium  produces  the 
excessive  proliferation  of  the  lutein  cells  in  the  ovary.  A  more 
probable  explanation  of  the  origin  of  a  vesicular  mole  is  that  which 
assigns  it  to  changes  in  the  decidua,  which  at  first  is  often  thickened 
and  exhibits  well-marked  inflammatory  processes.  The  efiect  which 
the  age,  multiparity,  and  certain  diseases  of  the  mother  appear  to 
have  and  the  fact  that  a  woman  may  have  a  hydatidiform  mole  in 
several  successive  pregnancies  is  evidence  in  favour  of  the  decidual 
origin.  The  changes  in  the  decidua  may  be  associated  with  some 
fault  of  development  in  the  foetal  portion  of  the  ovum.  This  is  the 
readiest  way  of  explaining  those  cases  in  which  there  are  twin  ova, 
of  which  one  is  developed  normally,  while  the  other  undergoes 
vesicular  degeneration. 

As  it  arises  from  the  chorionic  villi,  the  vesicular  mole  is  neces- 
sarily in  all  cases  the  product  of  conception  ;  it  does  not,  however, 
necessarily  imply  a  recent  conception,  for  the  diseased  structure 
may  be  retained  for  some  time  within  the  uterus,  and  afterwards 
grow  to  a  considerable  size. 

In  some  cases  a  foetus  has  been  born  at  full  term,  and  a  vesicular 


Diseases  of   Decidua  and   Ovum. 


527 


mole  has  been  expelled  some  months  later,  when  no  second  con- 
ception has  been  thought  possible.  This  may  be  explained  either 
on  the  ground  that  there  was  a  twin  ovum  which  had  undergone 
degeneration,  or  that  a  portion  only  of  the  vilU  of  the  first  ovum 


Fig.  287. — Uterus  containing  a  vesicular  mole.i     (Univ.  Coll.  Hosp.  Med. 
School  Mus.) 

had  undergone  this  change,  and  had  been  retained  in  consequence 
of  the  close  connection  which  they  form  with  the  uterine  wall. 
In  other  cases  again  a  vesicular  mole  has  been  expelled  first,  and 
a  living  ffjotus  some  months  after.     These  again  may  have  been 

1  See  I'roo.  Uoy.  Soc.  Med.  London,  March,  1909,  Obstetricnl  Section. 


528  The   Practice  of   Midwifery. 

instances  of  twin  pregnancy.  It  does  not  appear  that  a  piece  of 
normal  placenta  retained  in  the  uterus  at  the  expulsion  of  the  foetus 
can  afterwards  undergo  the  vesicular  degeneration.  Some  have 
maintained  the  theory  that  the  origin  of  the  vesicular  degeneration 
is  the  previous  death  of  the  foetus.  This  seems  to  be  disproved  by 
the  cases,  which  are  fairly  numerous,  in  which  a  living  foetus  has 
been  associated  with  partial  vesicular  change.  When  the  degenera- 
tion of  the  placenta  is  general  the  foetus  must  inevitably  perish  as 
a  secondary  result.  It  has  been  suggested  that  the  way  in  which 
the  death  of  the  embryo  acts  in  causing  a  vesicular  mole  is  that  the 
influence  of  the  foetal  thyroid  in  causing  embryonic  tissue  to  develop 
into  normal  connective  tissue  is  removed.  In  a  case  of  partial 
vesicular  degeneration  of  the  chorion,  diffused  throughout  the  whole 
placenta,  which  I  met  with,  associated  with  a  living  foetus  at  five 
months,  the  foetal  thyroid  was  specially  examined  from  this  point 
of  view,  and  reported  on  by  a  committee  of  the  Obstetrical  Society 
of  London.^  The  thyroid  was  found  to  be  quite  healthy  and 
normally  developed. 

The  condition  is  a  rare  one,  being  met  with  about  once  in  2,000 
pregnancies,  but  has  been  met  with  in  an  extra-uterine  gestation. 

Symptoms  and  Course. — At  first  the  symptoms  may  not  differ 
from  those  of  ordinary  pregnancy.  After  two  or  three  months  the 
enlargement  of  the  uterus  and  of  the  abdomen  is  often  more  rapid 
than  in  normal  pregnancy,  but  this  is  not  invariably  the  case.  When 
it  is  so,  constitutional  disturbance  may  be  set  up  by  the  unusual 
tension,  and  uterine  contractions,  threatening  abortion,  may  be 
excited.  Frequently  the  first  thing  which  attracts  attention  is  a 
sanguineous  discharge,  which  usually  sets  in  between  the  end  of  the 
first  and  the  third  month  of  pregnancy.  This  may  consist  either 
of  pure  blood,  or  of  a  more  watery  fluid,  compared  to  red-currant 
juice,  due  to  the  rupture  of  some  of  the  vesicles.  Sometimes 
clusters  of  vesicles  come  away  with  the  discharge,  and  the  com- 
parison is  then  to  white  currants  floating  in  red-currant  juice.  The 
haemorrhage  may  greatly  exhaust  the  patient,  or  even  lead  to  a 
fatal  result.  Eventually,  usually  at  the  fourth  or  fifth  month,  the 
uterus  may  either  expel  the  great  mass  of  the  mole,  leaving  other 
more  adherent  portions  behind,  or  it  may  completely  empty  itself.  In 
the  former  case,  very  considerable  haemorrhage  may  occur  or  recur  ; 
in  the  latter,  involution  of  the  uterus  takes  place  as  after  abortion  or 
delivery.  Sometimes  the  case  simulates  one  of  accidental  haemor- 
rhage, if  bleeding  has  taken  place,  the  uterus  is  much  distended, 
and  clot  only  can  be  felt  on  passing  the  finger  through  the  cervix. 

1  Trans.  Obst.  Soc,  London,  1903,  Vol.  XLV.,  p.  101. 


Diseases  of   Decidua  and  Ovum. 


529 


It  must  be  remembered  that  the  lower  segment  may  be  occupied  by 
clot,  and  the  mole  lie  above. 

Diagnosis. — An  absolutely  certain  diagnosis  can  only  be  made 
when  some  of  the  vesicles  are  discovered  in  the  discharge,  or  the 
mole  is  felt  by  the  finger  passed  through  the  cervix.  A  probable 
diagnosis  may  be  based  upon  the  following  points  :  the  size  of  the 
uterus  not  agreeing  with  the  duration  of  pregnancy,  especially  a 
too  rapid  increase  of  size ;  presence  of  haemorrhage  or  "  currant- 
juice"  discharge;  and  absence  of  any  tangible  parts  of  the  foetus, 


Fio.  288. — Section  of  uterine  wall  and  part  of  mole,  showing :  muscle 
fibres,  m  ;  small  celled  infiltration  in  spongy  layer  and  deepest  part  of 
compact  layer  of  decidua,  s.ci.  ;  the  fibrin  layer  of  Nitabuch,  ni  ;  the 
cell  layer  of  proliferating  epithelium  of  mole,  c.l.^ 

of  any  ballottement,  or  signs  of  foetal  life,  when  the  uterus  has 
reached  a  size  at  which  these  ought  to  be  discoverable  in  normal 
pregnancy.  The  uterus  often  has  a  peculiar  doughy  feel,  but  does 
not  fluctuate  as  in  a  case  of  hydramnios,  and  is  markedly  tender 
on  palpation.  In  partial  degeneration  of  the  placenta  with  a  living 
foetus  a  certain  diagnosis  is  practically  impossible. 

Pror/nosis. — The  result  is  generally  favourable,  if  adequate  treat- 
ment is  undertaken  early  enough.  The  danger  chiefly  depends 
upon  the  amount  of  blood  lost  and  the  risk  of  the  recurrence  of  the 

'  Sey  Proc.  Hoy.  Sjc.  Med.,  London,  iMarch,  lyo'J,  Obstetrical  Section. 

M.  84 


530  The   Practice  of   Midwifery. 

bleeding.  There  is  a  risk  also  of  septicaemia  and  other  post-jyartum 
disturbances,  to  which  the  loss  of  blood  and  the  operative  inter- 
ference -which  is  so  often  necessary  renders  the  patient  more  liable. 
The  rarer  cases,  in  which  the  growth  deeply  penetrates  the  uterine 
wall  in  a  quasi-malignant  manner,  are  always  dangerous,  since  they 
involve  the  risk  of  peritonitis  or  rupture  of  the  uterus. 

Chorion-epithelioma  (see  Chapter  XL.)  has  been  observed  after 
vesicular  moles  in  a  very  much  larger  proportion  of  cases  than  after 
normal  pregnancy  or  abortion.  Thus,  of  the  first  ninety  cases 
recorded,  forty -nine  followed  a  vesicular  mole,  which  is  a  very  rare 
disease. 

Treatment. — When  a  positive  diagnosis  has  been  made  by  in- 
spection of  some  of  the  vesicles  the  uterus  should  be  evacuated 
as  soon  as  possible.  The  only  exception  to  this  rule  is  the  rare 
case  in  which  the  presence  of  a  living  foetus  is  detected  in  addition 
to  the  mole.  If  the  haemorrhage  is  not  serious  the  physician  may 
then  defer  interference  in  the  hope  of  saving  the  foetus.  If  the 
diagnosis  is  only  probable,  the  decision  in  favour  of  evacuating 
the  uterus  or  otherwise  must  depend  upon  the  amount  of  haemor- 
rhage, and  its  effect  upon  the  patient's  condition.  It  is  to  be  remem- 
bered that  the  vesicular  mole  is  a  very  much  rarer  condition  than 
ordinary  pregnancy  with  haemorrhage,  due  to  threatened  abortion. 

If  the  OS  is  dilated,  and  the  expulsion  of  the  mole  has  commenced, 
the  evacuation  of  the  uterus  may  be  assisted  by  manipulation.  If 
not,  supposing  that  evacuation  is  resolved  upon,  the  cervix  must 
be  dilated  first  by  a  tent  if  necessary,  and  afterwards  by  Hegar's 
dilators  (see  Chapter  XXIV.),  or  may  be  plugged  with  gauze,  or 
hydrostatic  dilators  may  be  employed  if  the  uterus  is  very  large, 
until  it  will  admit  two  or  three  fingers.  The  patient  should  be 
placed  under  an  anaesthetic  for  the  evacuation.  A  full  dose  of  ergot 
may  be  administered  a  little  before,  or  ergotin  may  be  injected 
subcutaneously  at  the  time  of  operating,  in  order  to  gain  the  assist- 
ance of  the  uterus  in  expelling  the  mass  and  diminish  haemorrhage. 

The  patient  is  placed  in  the  dorsal  position  for  the  operation, 
and,  according  to  circumstances,  either  the  whole  hand  or  the  half- 
hand,  not  including  the  thumb,  is  passed  into  the  vagina.  The 
bladder  is  to  be  emptied  previously,  and  the  other  hand,  placed 
upon  the  abdomen,  presses  down  the  fundus  upon  the  fingers  in 
the  vagina.  In  general  it  is  sufficient  to  pass  two  fingers  into  the 
uterus  to  scoop  out  the  vesicular  mass.  After  the  lower  part  is 
removed,  the  contracting  fundus,  aided  by  the  external  pressure, 
brings  more  and  more  within  reach  of  the  fingers,  until  the  interior 
of   the   fundus   is  reached,   and  the  whole  cavity   evacuated.     If, 


Diseases  of   Decidua  and   Ovum.  531 

however,  the  uterus  is  very  greatly  enlarged  and  the  cervix  wide, 
four  fingers  or  the  whole  hand  may  be  passed  into  its  cavity.  In 
other  cases  again,  in  which  the  vagina  is  narrow,  the  evacuation 
may  be  effected  without  more  than  two  fingers  being  passed  into 
the  vagina,  the  uterus,  toward  the  end  of  the  process,  being  pushed 
down  close  to  the  outlet  in  a  position  somewhat  of  anteversion.  I 
have  known  the  lower  part  of  the  uterus  to  be  filled  with  a  mass  of 
clot ;  so  that  it  was  only  after  the  evacuation  of  a  large  part  of  this 
that  the  vesicular  mole  could  be  reached,  and  the  diagnosis 
positively  completed. 

If  the  vesicles  are  not  easily  detached  from  the  uterine  wall, 
care  must  be  taken  not  to  use  too  much  force  in  detaching  them. 
Otherwise,  in  a  case  in  which  the  growth  has  invaded  and  eroded 
the  uterine  wall,  a  rupture  reaching  the  peritoneal  surface  might 
be  produced.  The  operator  should  carry  the  separation  only  so 
far  as  he  can  effect  it  with  the  pulp  of  the  fingers,  not  using  the 
nails.  If  vesicles  are  left  embedded  in  the  uterine  wall,  they  will 
probably  be  destroyed  by  pressure,  if  the  cavity  is  once  thoroughly 
evacuated,  and  a  firm  contraction  secured.  After  the  operation, 
a  course  of  ergot  should  be  given  to  assist  involution.  If  it  has 
not  proved  possible  thoroughly  to  clear  the  cavity,  or  if  an  offensive 
discharge  from  it  appears,  the  uterus  should  be  periodically  washed 
out  with  an  antiseptic  solution.^  If  hsemorrhage  persists,  the 
cavity  of  the  uterus  should  be  explored  after  an  interval  (curetted 
and  the  scrapings  examined  microscopically),  while  the  possibility 
of  chorion-epithelioma  following  must  be  borne  in  mind. 

Hydramnios,  or  Hydrops  Amnii. — The  quantity  of  liquor 
amnii  varies  considerably  in  different  cases.  When  it  is  so  much 
in  excess  as  to  cause  constitutional  disturbance  to  the  patient,  the 
condition  is  called  Hydramnios. 

In  some  cases  the  amount  of  fluid  in  the  uterus  is  very  great,  as 
much  as  thirty  to  sixty  pints  having  been  met  with.  In  most  cases 
the  accumulation  of  the  fluid  takes  place  gradually,  but  in  a  few 
cases,  eight  of  623  observed  by  Lion,  it  occurs  rapidly.^ 

The  accumulation  may  occur  quite  in  the  early  months  of 
pregnancy,  and  no  doubt  inlays  some  part  in  the  production  of  the 
so-called  hsematomatous  mole. 

Causation. — In  some  cases,  hydramnios  has  been  observed  in 
conjunction  with  certain  morbid  conditions  in  the  mother,  such  as 

1  Solution  of  perchloride  of  mercury  (1  in  4,000)  ;  Tinct.  lodi,  3ij,  ad  aq.  Oj  :  or 
lysol,  1  per  cent.,  may  be  used. 

^  Lion,  Ai'chiv  de  Tocol  et  Gyn.,  ]8y7.  Bd  23. 

34—2 


532  The   Practice  of   Midwifery. 

leucaemia,  chronic  anfemia,  nephritis,  and  grave  heart  disease, 
which  ajDpear  to  have  something  to  do  with  the  causation.  In 
general,  however,  the  fault  is  rather  on  the  foetal  side.  This  is 
shown  by  the  fact  that  hydramnios  is  specially  frequent  in  twin 
pregnancy,  but,  as  a  rule,  only  one  of  the  ova  is  affected  in  this 
way.  Again,  in  a  large  proportion  of  cases  (about  75  per  cent, 
according  to  McClintock),  the  foetus  has  been  found  to  be 
of  the  female  sex.  The  foetus  is  rarely  quite  perfectly 
developed  or  well  nourished,  and  in  a  considerable  proportion  of 
cases  is  born  dead  or  dies  soon  after  delivery.  This  may  be 
due  in  part  to  the  premature  delivery  which  is  common  in  such 
eases.  A  considerable  number,  however,  of  the  foetuses  (15 
per  cent,  according  to  McClintock)  are  dead  and  macerated  before 
delivery. 

In  about  50  j)er  cent,  of  the  cases  the  placenta  is  found  in 
some  way  anomalous,  either  unusually  large  or  oedematous,  the 
result  of  some  interruption  to  the  placental  circulation.  The 
causation,  therefore,  probably  varies  in  different  cases.  (1)  It  may 
result  from  an  inflammation  of  the  amnion  itself,  the  effect  of 
which  is  sometimes  shown  by  adhesions  of  the  amnion  to  the 
foetus,  or  bands  traversing  the  amnial  cavity.  The  cells  lining 
the  amnion,  altered  by  inflammation,  may  determine  an  exces- 
sive transudation  tow^ard  the  amnial  cavity.  (2)  In  the  common 
cases  in  which  hydramnios  is  associated  with  some  fcetal  deformity, 
as  in  19  of  23  cases  recorded  by  Ahlfeld,  the  deformity  is  probably 
generally  the  primary  cause.  Thus  in  extroversion  of  the  viscera 
the  vessels  are  less  covered  than  usual,  and  allow  more  ready 
transudation.  In  abnormalities  of  the  circulatory  system,  there  is 
generally  some  obstruction,  and  excessive  pressure  in  the  placental 
vessels,  stenosis  or  thrombosis  of  the  umbilical  vein,  or  torsion  of 
the  cord.  Cirrhosis  of  the  foetal  liver,  syphilitic  or  non-syphilitic 
valvular  disease  of  the  heart,  and  stenosis  of  the  aorta,  pulmonary 
artery,  or  ductus  arteriosus  are  among  the  pathological  changes 
which  have  been  recorded.  (3)  When  hydramnios  is  associated 
with  twin  pregnancy,  the  twins  are  frequently  developed  from  one 
ovum,  having  a  single  chorion,  the  placenta  being  single  ;  the 
vessels  of  the  twins  communicating,  about  one-twentieth  to  one- 
fifth  of  the  whole  placenta  being  common  to  the  two.  The 
hydramnios  is  explained  on  the  ground  that  such  twins  have  often 
some  deformity,  or,  at  any  rate,  abnormality  in  the  placental 
circulation.  For  example,  the  umbilical  cord  of  the  affected  twin 
may  be  velamentous.     According  to  Wilson,^  the  following  is  the 

1  Trans.  Obst.  Soc.  London,  1899,  Vol.  XLL,  p.  235. 


Diseases  of   Decidua  and   Ovum.  533 

explanation  of  the  hydramnios  in  these  cases.  The  twin  whose 
vessels  run  a  shorter  or  more  direct  course  obtains  an  undue  share 
of  blood  from  the  placenta.  In  consequence  it  grows  faster  than 
the  other,  and  its  heart  becomes  hyj)ertrophied.  This  leads  in 
some  way  to  an  increased  uptake  of  fluid  in  the  placenta.  The 
kidneys  also  become  hyper trophied,  and  there  is  increased  exudation 
certainly  from  the  kidneys,  and  probably  also  from  the  skin  and 
the  portions  of  placenta  belonging  to  the  affected  foetus.  The 
result  is  hydramnios  of  the  larger  twin  rapidly  produced  about  the 
fourth  or  fifth  month,  and  ending  usually  in  premature  delivery 
before  the  end  of  the  seventh  month.  The  smaller  twin  has  a 
normal  or  deficient  quantity  of  liquor  amnii,  and  its  heart  is 
sometimes  found  to  be  thin.  Kiistner^  maintains  that  there  is 
generally  some  obstruction  in  the  placental  circulation  of  one  twin 
which  leads  to  increased  work  on  the  part  of  its  heart  and  resulting 
cardiac  hypertrophy.  The  increased  cardiac  action  in  its  turn  leads 
to  a  gradual  extension  of  its  placental  territory,  and  so  to  its  better 
nutrition.  Finally,  the  hypertrophied  heart  is  unable  to  meet  the 
demands  upon  it,  it  begins  to  fail,  and  thus  result  venous  stasis,  hyjjer- 
trophy  and  later  atrophy  of  the  liver,  dropsy,  and  hydramnios.  Wilson 
found  that,  out  of  101  cases  of  hydramnios,  46  occurred  in  twins, 
and  4  in  triplets.  Of  the  46  twin  cases,  at  least  2'2  appear  to  have 
been  of  the  unioval  variety,  although  twins  developed  from  different 
ova  are  seven  times  as  common  as  unioval  twins.  (4)  The  rarest 
form  seems  to  be  that  due  to  disease  of  the  mother,  such  as  syphilis 
or  antemia.  In  this  case  there  may  be  general  dropsy  of  the 
placenta,  as  well  as  hydramnios. 

Symptoms  and  ■  Course. — The  symptoms  are  the  effect  of  the 
mechanical  pressure  due  to  the  rapid  increase  in  size  of  the 
uterus.  This  increase  generally  does  not  become  manifest  before 
the  fifth  month,  but  it  may  go  on  so  rapidly  that  the  uterus  is 
soon  much  larger  than  it  usually  is  at  the  full  term  of  pregnancy. 
The  symptoms  are  then  similar  to  those  produced  by  a  large  ovarian 
tumour.  There  is  pain  from  tension  and  the  weight  of  the 
abdominal  contents,  dyspnoea  and  palpitation  from  interference  with 
the  diaphragm,  and  disturbed  digestion,  also  from  the  effect  of 
pressure.  The  urine  is  often  scanty,  and  when  tension  is  very 
great,  it  may  become  albuminous.  There  is  often  oedema  of  feet 
and  legs,  and  this  may  extend  to  the  vulva  and  lower  part  of 
abdomen.  Often  spontaneous  relief  is  afforded  by  the  occurrence 
of  premature  labour.     The  first  stage  of  labour  is  apt  to  be  tedious 

1  Kustner,  Arch.  f.  Gyn.,  1870,  Bd.  10,  s.  134,  Hft.  1,  1883,  Bd.  21,  s.  1,  Hffc.  1  ; 
Werth,  Arch.  f.  Gyn,,  1882,  Bd.  20,  s.  353,  Hft.  3. 


534  The   Practice  of   Midwifery. 

from  the  over-distension  of  the  uterus.  From  the  same  cause, 
there  is  a  greater  proneness  than  usual  to  post-partiim  haemorrhage, 
as  there  is  in  the  case  of  twins. 

Diagnosis. — There  may  be  difficulty  in  diagnosis  when  the 
collection  of  fluid  is  very  great,  and  the  foetus  small  or  dead,  so 
that  the  foetal  heart  and  movements  cannot  be  detected.  I  have 
met  with  several  cases  in  which  the  uterus  had  been  tapped  in  the 
belief  that  it  was  an  ovarian  cyst,  not  always  with  the  result  of 
bringing  on  labour.  The  softened  state  of  cervix  and  expansion  of 
lower  segment  of  uterus,  as  felt  j^er  vaginam,  combined  with  a 
history  of  amenorrhoea,  will  generally  prove  pregnancy.  Frequently 
also,  although  the  distended  uterus  may  give  a  fluid  wave  or 
thrill  as  distinct  as  that  to  be  detected  in  an  ovarian  cyst,  the 
firm  body  of  the  foetus  may  be  felt  on  dipping  for  it  with  the 
fingers  in  the  midst  of  the  fluid  mass,  especially  if  the  patient  be 
placed  upon  the  side  or  in  the  knee-elbow  position.  The  difficulty 
which  sometimes  arises  is  that  of  distinguishing  between  hydram- 
nios  and  an  ovarian  cyst  complicating  pregnancy.  For  although 
the  body  of  the  pregnant  uterus  may  generally  be  made  out  as 
separate  from  the  ovarian  cyst,  this  may  not  be  possible  if  disten- 
sion is  extreme.  The  most  valuable  distinction  of  all  is  to  be  found 
in  the  fact  that,  notwithstanding  the  over-distension  of  the  uterus, 
the  intermittent  uterine  contractions,  a  most  important  sign  of 
pregnancy  (see  p.  180),  may  still  generally  be  detected  in  it, 
especially  if  excited  by  manipulation.  A  hardening  of  the  wall  of 
the  tumour  is  thus  produced,  and  if  it  can  be  made  certain  that 
the  hardening  extends  to  the  whole  tumour,  it  is  proved  that  the 
whole  of  it  is  uterus.  Another  useful  distinction  may  often  be 
found  in  the  fact  that,  when  the  uterus  is  so  distended  as  to  simulate 
a  large  ovarian  cyst,  there  is  generally  some  yielding  of  the  cervix, 
more  than  exists  normally  at  the  fifth  or  sixth  month  of  pregnancy, 
so  that  the  finger  may  be  pressed  into  it  far  enough  to  reach  the 
membranes. 

In  minor  cases  of  hydramnios,  the  distinction  has  to  be  made 
from  twin  pregnancy.  This  may  be  done  by  obtaining  the  positive 
signs  of  the  existence  of  twins  (see  p.  372),  in  the  one  case,  or  by 
noting  the  altered  consistency  of  the  uterus  from  the  excess  of  fluid 
within  it  in  the  other,  and  the  fact  that,  in  the  case  of  hydramnios 
of  one  of  twins,  the  fluid  thrill  is  not  transmitted  to  all  parts  of 
the  uterus  when  the  sac  of  the  healthy  foetus  is  palpable  as  well  as 
that  of  the  hydramniotic  foetus. 

Treatment.— In  mild  cases,  all  that  can  be  done  is  to  prescribe 
rest,  and  the  support  of  the  uterus  by  an  abdominal  belt.     If  serious 


Diseases  of   Decidua  and  Ovum. 


535 

This 


constitutional  disturbance  is  caused,  labour  must  be  induced, 
was  necessary  in  20  per  cent,  of  Wilson's  cases. 

It  is  desirable,  if  possible,  to  wait  until  the  child  is  viable. 
Sometimes,  however,  it  is  necessary  to  interfere  before  this,  and 
there  need  be  less  reluctance  to  do  so  from  the  fact  that,  in  such  a 
case,  there  is  little  chance  of  a  healthy  child  surviving. 

The  foetal  mortality  is  about  25  per  cent,  in  chronic  cases,  and 
much  higher  than  this  in  acute  cases.  The  danger  to  the  mother 
results   from  the  over-distension  of  the  uterus,  the  resulting  risk 


Fig.  289. — Placenta  velamentosa. 


of    i)ost-imrtum    hgemorrhage,    and    the    necessity    for    operative 
interference. 

If  there  is  a  hope  of  saving  the  child^  the  induction  of  labour 
may  be  commenced  by  passing  an  elastic  bougie  into  the  uterus  in 
the  mode  hereafter  to  be  described  (see  Chapter  XXXI.),  or  by 
introducing  a  small  dilating  bag.  If  not,  there  is  no  object  in 
keeping  the  membranes  intact.  The  membranes  may  then  be 
ruptured  by  passing  a  sound  or  stylet  through  the  cervix.  In  the 
first  stage  of  labour,  when  it  comes  on  spontaneously,  it  will  often 
be  necessary  to  stimulate  the  over-distended  uterus  to  contraction 
by  rupturing  the  membranes  early  and  evacuating  the  liquor 
amnii,  if  this  has  not  already  been  done.  After  delivery,  a  dose  of 
ergot  should  be  given,  and  special  care  taken  to  guard  against  post- 
partum hgemorrhage. 


536 


The   Practice  of   Midwifery. 


Deficiency  of  Liquor  Amnii. — Deficiency  of  liquor  amnii  in 
the  later  months  may  lead  to  protraction  of  the  first  stage  of 
labour,  the  fluid  being  insufficient  to  form  a  properly  bulging  bag 
of  membranes. 

As  the  amniotic  cavity  is  formed  within  a  solid  mass  of  cells, 
if  it  does  not  develop  properly,  adhesions  may  exist  between  the 
cells  of  the  amnion  and  those  of  the  embryonic  plate  of  the  foetus, 
and  as  growth  proceeds  these  may  become  drawn  out  and  form 
amniotic  bands,  which  play  an  important  part  in  the  production  of 
foetal  deformities  and  intra-uterine  amputation  of 
limbs. 

Anomalies  of  the  Funis. — Velamentous  Inser- 
tion.— A  completely  central  insertion  of  the  cord 
is  not  at  all  common,  occurring  in  only  3  per 
cent,  of  all  placentfe.  In  56  per  cent,  it  is 
excentrically  situated,  in  31  per  cent,  near  the 
edge  of  the  placenta,  and  actually  at  the  margin 
in  some  5  per  cent.  The  most  important 
anomaly  in  the  insertion  of  the  cord  is  that  in 
which  it  has  its  attachment,  and  breaks  up  into 
its  constituent  vessels  on  tbe  membranes  some 
distance  from  the  edge  of  the  placenta,  the  so- 
called  placenta  relamentosa.  This  occurs  in 
about  '5  per  cent,  of  placentae,  and  is  especially 
frequent  in  cases  of  placenta  prsevia  and  with 
multiple  pregnancies.  The  most  probable  ex- 
planation of  this  anomaly  is  that  put  forward 
by  V.  Franque,^  viz.,  that  in  some  cases  the 
decidua  reflexa  is  as  vascular  as,  or  even  more 
vascular  than,  the  neighbouring  part  of  the 
decidua  basalis,  and  in  these  conditions  the 
vessels  in  the  abdominal  stalk  may  have  a  free  vascular  connection 
with  the  decidua  reflexa,  and  in  this  position  the  umbilical  cord  may 
ultimately  develop.  When  this  is  the  case  the  umbilical  vessels  will 
have  primarily  an  attachment  to  a  portion  of  the  decidua  which 
finally  becomes  applied  to  the  chorion.  The  vessels  of  a  i^lacenta 
velamentosa  may  be  torn  or  j)ressed  upon  during  labour,  and  some 
18  per  cent,  of  the  children  in  these  cases  are  born  asphyxiated. 

Knots. — A  knot  in  the  funis  is  produced  by  the  foetus  passing 
through  a  loop  in  it.     This  occurs  either  in  the  early  months  of 

1  V.  Franque,  Zeitschrift  f.  Geb.  u.  Gyn.,  1894,  Bd.  28,  ss.  293—348. 


Fig.  290.— Knot  of 
umbilical  cord. 


Diseases  of   Decidua  and   Ovum. 


537 


■  pregnancy  or  only  in  labour.  It  is  favoured  by  the  funis  being 
unusually  long,  so  that  a  loop  is  readily  formed  towards  the  lower 
part  of  the  uterus.  Complex  knots  may  be  produced  if  the  foetus 
passes  twice  or  more  through  the  loop.  In  general,  the  knot  is  not 
drawn  so  tight  as  to  obstruct  the  circulation,  and  it  has  then  little 
practical  effect.  If  the  knot  is  formed  only  in  labour,  generally  no 
mark  remains  upon  the  funis  when  it 
is  undone.  If  it  is  of  longer  standing, 
the  gelatinous  substance  of  the  cord 
is  found  to  have  disappeared  at  the 
points  exposed  to  pressure.  In  rare 
cases,  the  knot  becomes  drawn  so  tight 
that  the  fcetus  perishes,  generally  in 
the  earlier  months  of  pregnancy. 

Coils. — The  funis  may  be  coiled 
once,  twice,  or  oftener,  round  the 
neck  of  the  foetus,  or  round  the  limbs. 
A  coil  round  the  neck  may  be  regarded 
as  the  first  stage  toward  the  formation 
of  a  knot  in  the  cord,  the  head  only, 
and  not  the  whole  fcetus,  having  passed 
through  the  loop.  Coils,  like  knots, 
are  most  likely  to  be  formed  when 
the  funis  is  longer  than  usual.  Coils 
round  the  neck  generally  come  into 
practical  operation  only  during  labour. 
They  then  shorten  the  length  of  funis 
available,  and  so  may  cause  obstruc- 
tion to  labour,  or  detachment  of  the 
placenta.  These  difficulties  in  labour 
will  be  considered  hereafter  (see 
Chapter  XXVIII.).  They  may  also 
cause  death  of  the  foetus  by  strangula- 
tion, when  put  on  the  stretch  with  the  advance  of  labour.  In  rare 
cases,  a  coil  or  coils  round  the  neck  become  so  tight  in  the  course 
of  pregnancy  as  to  destroy  the  fcetus.  Sometimes  even  the  head 
is  nearly  amputated  by  the  constriction.  It  is  believed  that  intra- 
uterine amputation  of  limbs  also  may  sometimes  be  produced  by 
constriction  through  a  coil  of  funis,  but  it  is  probably  due  much 
more  frequently  to  a  band  resulting  from  amnial  adhesions.-^ 


Fig.  291. — Coiling  of  cord  round 
neck  of  foetus. 


1    V.  Fraii<|u<^,  Zeilsehriffc  f.  Geb.  u.  Gyn,,  1894,  Hd.  28,  ss,  29.S— 8-18. 


538  The   Practice  of   Midwifery. 

Torsion. — It  has  already  been  explained  that  the  vessels  of  the 
funis,  originally  straight,  become  gradually  twisted  as  pregnancy 
advances,  from  the  rotations  of  the  fcetus  in  one  direction  prepon- 
derating over  those  in  the  other  direction.  The  same  cause  acting 
in  a  more  sudden  or  rapid  manner,  may  cause  actual  torsion  of  the 
whole  funis  to  such  an  extent  that  the  calibre  of  the  vessels  is  more 
or  less  obstructed.  The  torsion  is  generally  most  marked  near 
the  umbilicus,  Wharton's   jelly   being  thinner  at  that  part,  and 


^ 


/^'S^ 

^o^^^- 


Fig.  292.— Torsion  of  the  cord.     (Univ.  Coll.  Hosp.  Med.  School  Mus.) 

the  resistance  of  the  funis  being,  therefore,  less.  The  torsion 
may  affect  the  whole  cord  or  only  a  circumscribed  part  of  it, 
and  in  the  latter  case  it  is  possible  for  the  cord  to  be  twisted 
entirely  through.  This  only  occurs,  however,  with  dead  or 
macerated   foetuses. 

It  may  be  produced  either  after  the  death  of  the  foetus  or  during 
its  life.  In  the  former  case,  it  must  be  due  solely  to  rotations 
produced  by  movements  of  the  mother  and  external  pressures.  It 
will  take  place  more  readily  from  the  fact  that  the  firmness  of  the 
funis,  and  its  consequent  resistance  to  torsion,  is  diminished  by 
death.  Torsion  of  the  funis  during  the  life  of  the  fcetus  may  be 
due  both  to  fcetal  movements,  and  to  maternal   movements  and 


Diseases  of   Decidua  and  Ovum.  539 

pressures,  probably  for  the  most  part  to  the  former.  By  causing 
obstruction  of  the  vessels  it  may  lead  to  the  death  of  the  foetus. 
In  individual  cases,  it  is  difficult  to  determine  whether  the  torsion 
is  the  consequence  or  the  cause  of  the  death  of  the  fcetus.  In  a 
considerable  proportion  of  the  cases  there  is  evidence  that  it 
occurred  after  the  death  of  the  foetus,  first  because  the  degree  of 
torsion  is  much  greater  than  would  be  sufficient  to  kill  the  fcetus, 
and  secondly,  because  other  sufficient  cause  of  its  death,  such  as 
the  presence  of  syphilis,  is  discovered.  On  the  other  hand,  the 
facts  that  it  is  commoner  with  male  than  with  female  children,  that 
the  twisting  of  the  cord  cannot  be  undone,  and  that  children  are 
not  infrequently  born  alive'  with  marked  torsion  of  the  cord,  are 
in  favour  of  its  ante-mortem  occurrence. 


Anomalies  and  Diseases  of  the  Fcetus. 

The  foetus  is  subject  to  innumerable  faults  of  development,  and 
to  a  considerable  number  of  diseases.  For  these,  the  reader  is 
referred  to  works  on  malformations,  and  on  diseases  of  children.^ 
Space  will  allow  here  only  a  brief  reference  to  a  very  few  conditions 
which  have  a  special  obstetric  interest. 

Intra-uterine  Amputation  of  Limbs. — Limbs  occasionally 
present  the  appearance  of  having  been  amputated,  the  stump 
having  healed  over,  with  what  appear  to  be  the  rudiments  of  fingers 
or  toes  attached  to  the  end  of  it.  At  one  time  the  view  was  held 
that  these  were  the  result  of  amputation  by  constriction  by  the 
umbilical  cord,  but  this  is  certainly  not  the  case,  and  more  recent 
observations  tend  to  show  that  they  are  either  the  result  of  mal- 
development  or  of  pressure  by  amniotic  bands  due  to  imperfect 
formation  of  the  amniotic  cavity  and  acting  at  a  very  early  stage 
in  the  development  of  the  embryo. 

Congenital  dislocations,  so  called,  affect  most  frequently  the 
hip-joint,  and,  next  to  that,  the  shoulder.  In  most  cases,  at  any 
rate,  the  condition  is  really  due  to  a  fault  of  development  rather 
than  to  dislocation,  the  articular  cavities  being  formed  in  an 
abnormal  position  or  undeveloped,  while  the  actual  dislocation  may 
take  place  in  some  instances  during  the  act  of  birth. 

1  See  Forstcr,  Misbildungen  der  Menschen,  1801  ;  Ahlfeld,  Die  Misbildungen  der 
Menschen,  mit  Atlas,  1880;  Noble  Smith,  The  Surgery  of  Deformities;  Baliantyne, 
Antenatal  I'athology  and  Hygiene  :  The  Foetus,  1902,  The  Embryo,  li)04  ;  Taruffi, 
Storia  della  Teratologia,  Bologna,  1881 — 1894. 


540  The   Practice  of   Midwifery. 

Intra-uterine  Fracture  of  Bones.— Apart  from  the  fracture 
of  bones  which  may  arise  in  difficult  labour,  whether  completed 
naturally  or  artificially,  cases  of  intra-uterine  fracture  have  also 
been  observed.  The  limbs,  as  being  the  parts  most  exposed,  are 
chiefly  affected,  and  more  especially  the  thighs.  Cases  have 
been  recorded  in  which  as  many  as  thirty  to  a  hundred  fractures 
have  been  met  with,  affecting  almost  all  the  bones. ^ 

Possibly  such  cases  are  to  be  explained  as  instances  of  excessive 
fragility  of  the  bones  and  excessive  foetal  movements  or  externa 
violence.  Other  cases,  however,  accompanied  as  they  often  are  by 
malformations  of  other  parts  of  the  body  and  the  presence  of  scars 
over  the  sites  of  the  fractures,  can  only  be  explained  by  supposing 
that  they  are  the  results  of  mal-developments  having  their  origin 
in  amniotic  adhesions  or  bands  the  result  of  faulty  develoj^ment 
from  formation  of  the  amniotic  cavity.  Dislocation  is  apt  to  be 
added  to  the  fractures,  from  the  effect  of  the  traction  of  muscles 
acting  upon  the  separated  fragments.  In  other  cases,  separation  of 
the  bones  results,  not  from  actual  fracture,  but  from  failure  of 
union  between  different  centres  of  ossification  or  separation  of 
epiphyses,  sometimes  the  result  of  inflammation.  This  may  result 
from  syi^hilis,  as  well  as  from  rachitis. 

Anencephalus. — In  this  abnormality  the  brain  is  absent,  and 
the  head  consists  only  of  the  face  and  base  of  the  skull,  the  bones 
forming  the  vault  being  rudimentary.  It  is  developed  either  from 
the  bursting  of  a  hydrocephalus  or  as  a  result  of  amniotic  pressure 
or  amniotic  bands.  It  is  difficult  to  regard  the  first  cause  as  an 
important  one  when  we  remember  that  in  these  cases  as  a  rule  the  base 
of  the  skull  remains  convex  and  the  fact  that  the  eyes  are  occasion- 
ally perfectly  formed.  It  is  probable  that  cases  of  complete  absence 
of  the  cranium  are  due  to  amniotic  pressure,  while  those  of  partial 
anencex3haly  are  the  result  of  amniotic  adhesions  interfering  with 
the  due  development  of  the  parts.^  The  body  is  usually  well 
developed,  and  the  shoulders  broad.  The  child  may  live  for  a  few 
hours  or  even  for  several  days  after  delivery,  for  sixteen  in  one 
recorded  case.^ 

Deficient  Closure  of  Abdominal  ^A/'alls,  or  Exomphalos. — In 

the  early  stage  of  foetal  existence  a  portion  of  the  intestine  normally 
projects  outside  the  abdomen  at  the  umbilicus.     Sometimes  there 

.1  Linck,  Archiv  f.  Gyn..  1887,  Vol.  XXX.,  s.  261,  Hft.  2  ;  Chaussier,  Bull.  Fac.  de 
Med.  de  Paris,  1813,  Vol.  III.,  p.  301. 

2  Ballantyne,  Antenatal  Pathology  :  The  Embryo,  1904,  p.  348. 

3  Ross,  Trans,  Obst.  Soc.  London,  1868,  Vol.  IX..  p.  31. 


Diseases  of   Decidua  and  Ovum.  541 

is  a  failure  in  the  natural  process  by  which  this  portion  of  intestine 
is  drawn  into   the  abdominal  cavity  and  the  abdominal  walls  are 
closed  in.     A  kind  of  hernial  sac  then  exists  at  the  time  of  birth, 
generally  covered  only  by  amnion,  as  the  peritoneum  is  usually 
wanting.     The  size  of  the  sac  varies  greatly  ;  sometimes  it  contains 
only  some  coils  of  intestine,  frequently  a  part  of  the  liver  also. 
Sometimes  nearly  the  whole  of  the  abdominal  contents,  including 
the  stomach,  liver,  spleen,  and  even  the  heart  and  lungs  when  the 
deficiency  involves  the  thorax,  are  outside  the  body.     The  funis  is 
generally  attached  towards  the  summit,  or  near  the  lower  part,  of 
the  protuberant  mass,  and  the  vessels,  often  only  a  single  artery 
and  vein,  divide  and  spread  out  over  the  amnion.     Sometimes  the 
funis  is  abnormally   short  or 
even   absent.      The   condition 
is  often  combined  with  mal- 
formations in   other   parts  of  # 
the  body. 

When  the  extruded  mass  of 
viscera  is  large,  it  may  form  i  y 

the   presenting    part,    and    it  ,/  .r- 

may  then  give   rise   to    some  -" 

difficulty   in   diagnosis.      The  -v^/^ 

child  will   generally  be  inca- 
pable of  surviving. 

Eetroflexion    of    the    spine 
and  absence  of  certain  of  the      ^m.  293.-Spirochaeta  pallida  from  blood 

.  smear.     One  red  corpuscle  is  shown. 

lumbar      vertebrae     is      very 

common,  the  foetus  being  in  a  position  of  marked   opisthotonos. 

Postnatal  life  as  a  rule  is  very  short. 

Hydrocephalus, Spinabifida, Meningocele, Encephalocele, and 
Tumours — These  conditions  will  be  described  in  Chapter  XXVIII. 
under  the  head  of  obstructions  to  labour. 

Syphilis. — Syphilis  in  the  fcetus  may  be  inherited  from  the 
mother,  from  the  father  and  the  mother,  or  from  the  father,  the 
mother  either  developing  secondary  symptoms,  or  showing  no  signs 
of  the  disease  and  yet  being  immune  and  not  capable  of  infection 
from  her  syphilitic  child.  It  may  also  be  derived  from  the  mother 
if  she  be  infected  with  syphilis  between  probably  the  end  of  the 
first  and  the  end  of  the  seventh  month  of  pregnancy.  Syphilis  is 
the  commonest  cause  of  repeated  abortions  and  miscarriages,  and 
may  kill  the  foetus  either  by  the  affections  of  the  placenta  which  have 


542 


The  Practice  of   Midwifery. 


already  been  described  or  by  its  direct  effect  upon  the  foetus  itself. 
It  is  often  associated  with  hydramnios. 

When  the  foetus  has  perished  before  birth  it  is  often  macerated 
and  wasted,  and  may  or  may  not  show  definite  evidence  of 
syphilis. 

Even  when  born  alive  it  may  be  puny  and  ill  nourished,  even 
although  it  shows  no  signs  of  syphilis  at  birth.  It  may,  however, 
exhibit  various  congenital  malformations.    In  other  cases  the  signs 


Fig.  29i.- 


-Tibia  from  a  healthy  and  from  a  syphilitic  foetus.    The  thickening 
of  the  epiphysial  line  in  the  latter  is  to  be  noted. 


of  syphilis  may  be  present  at  birth  or  may  develop,  as  is  usually 
the  case,  about  the  end  of  the  first  month. 

The  most  characteristic  eruption  of  the  skin  at  birth  is  pem- 
phigus, affecting  especially  the  palms  of  the  hands  and  feet,  but 
sometimes  other  i3arts  of  the  body  also.  This  may  lead  to  detach- 
ment of  large  flakes  of  skin  even  in  the  living  foetus.  It  is,  however, 
a  rare  condition,  occurring  in  only  some  2  per  cent,  of  syphilitic 
foetuses. 

Syphilis  in  the  foetus  is  peculiar  in  presenting  no  primary  stage, 
and  shows  itself  chiefly  in  the  general  nutrition,  the  skin,  the 
viscera,   and   the   bones.      Copper-coloured    stains,    condylomata, 


Diseases  of   Decidua  and  Ovum.  543 

mucous  patches,  and  erosions  and  cracks  around  the  mouth  are 
the  symptoms  usually  developing  about  the  end  of  the  first  month 
of  life.     The  viscera  chiefly  affected  are  the  spleen,  liver,  and  lungs. 

The  changes  in  them  are  chiefly  of  two  kinds,  which  may 
be  found  together  or  separately.  These  are  interstitial  deposits 
of  cellular  or  fibroid  tissue  causing  enlargement  with  elastic 
induration  of  the  organ,  and  gummata  in  the  form  of  granules  or 
small  patches.  Thus  in  the  liver  there  may  be  either  "  miliary 
gummata  "  compared  to  semolina  grains,  or  more  rarely  gummata 
of  larger  size.  Sometimes  the  gummata  break  down  into  small 
abscesses.  Peritonitis,  usually  secondary  to  visceral  lesions,  is 
common.  One  of  the  most  constant  of  all  the  manifestations  of 
syphilis  in  the  foetus  is  said  to  be  an  inflammation  in  the  long 
bones  of  the  limbs.  The  so-called  osteochondritis  of  Wegner,  at 
the  junction  of  the  cartilage  of  the  ej)iphysis  with  the  bone,  exces- 
sive proliferation  of  the  cartilage  cells,  takes  place,  with  resulting 
compression  of  the  blood-vessels,  so  that  the  proliferating  cells 
degenerate  and  undergo  fatty  changes.  Hence  a  yellowish  or 
orange-coloured  line  is  seen  at  the  junction  of  the  epiphysis 
much  thicker  than  the  normal  white  line  in  this  situation.  This 
change  is  most  characteristically  seen  at  the  lower  epiphysis  of  the 
humerus  and  of  the  radius  and  the  upper  of  the  tibia. 

In  some  cases  the  degenerative  changes  may  go  on  to  softening, 
and  in  this  softened  tissue  suppuration  may  occur  if  it  becomes 
infected  with  pyogenic  organisms. 

Treatment. — When  either  parent  shows  signs  of  syphilis ;  when 
previous  abortions  have  occurred,  attributable  to  syphilis ;  or  when 
the  previous  child  has  suffered  from  congenital  syphilis,  the  mother 
should  be  treated  during  pregnancy  with  the  view  that  the  drug 
may  reach  also  the  foetal  circulation.  Perchloride  of  mercury  may 
be  given  three  times  a  day  after  meals  in  doses  of  -^  to  -^2  gi'ain, 
combined  with   a  little  hydrochloric  acid  and  syrup. 

Congenital  Rachitis. — In  rare  cases  the  foetus  is  affected  by  a 
disease  closely  resembling,  and  apparently  identical  with,  the 
rachitis  of  children.  There  is  great  deficiency  of  earthy  material 
and  abnormal  softness  of  all  the  bones,  and  the  limbs  are  stunted, 
thickened  and  bent.  The  abdomen  is  swollen  and  the  liver 
enlarged.  At  the  epij^hyses  of  the  long  bones  and  of  the  ribs  there 
is  thickening  which,  according  to  Spiegelberg,  is  due  to  an  exces- 
sive proliferation  of  the  cells  engaged  in  the  formation  of  bone, 
identical  with  that  which  occurs  in  ordinary  rachitis.  Depaul, 
however,  contends  that  the  disease  is  not  the  same  as  the  rachitis 


544  The  Practice  of   Midwifery. 

of  children.  The  general  changes  of  shape  in  the  bones  are 
similar  to  those  produced  by  ordinary  rachitis.  The  stunted  and 
thickened  aj)j)earance  of  the  limbs,  however,  is  much  more  marked, 
and  the  head  is  unduly  large  in  proportion  to  the  body  and  limbs. 
Sometimes  the  cranial  bones  are  imperfectly  ossified,  exhibiting 
well-marked  craniotabes,  and  sometimes  there  is  hydrocephalus. 
There  may  be  fractures  of  the  bones  (see  p.  540),  which  are  some- 
times found  united,  or  partially  united,  at  the  time  of  birth.  Since 
the  weight  of  the  body  cannot  come  into  play,  the  changes  of  shape 
in  the  skeleton,  including  a  flattening  of  the  pelvis  in  its  antero- 
posterior diameter,  and  widening  of  the  pubic  arch,  must  be  due 
to  the  traction  and  pressure  of  muscles  and  ligaments  combined 
with  external  pressure.  The  bones  in  early  fcetal  life  will  have 
less  power  of  resisting  these  forces  than  those  of  a  child  similarly 
affected. 

The  causation  of  intra-uterine  rachitis  is  obscure,  since,  in  the 
recorded  cases,  malnutrition  on  the  mother's  part  was  not  apparent. 
The  disease  is  especially  liable  to  occur  in  twin  pregnancy.  One 
foetus  only  has  been  found  affected,  when  the  placentae  were 
separate ;  and  both  foetuses  when  there  was  a  single  conjoint 
placenta.  This  is  evidence  in  favour  of  the  view  of  Spiegelberg, 
that  the  cause  is  not  so  much  any  malnutrition  in  the  mother,  as 
some  unknown  condition  in  the  placenta. 

According  to  Ballantyne,  foetal  bone  diseases  may  be  arranged 
in  a  series  of  types,  at  one  extreme  being  a  disease  resembhng 
infantile  rachitis,  probably  coming  on  in  the  later  months  of  preg- 
nancy, at  the  other  the  disease  which  has  been  described  as 
achondroplasia  or  chondrodystrophia  foetalis.  The  chief  character 
of  this  is  shortness  of  the  limbs,  due  to  the  diaphyses  of  the  long 
bones  being  only  one-half  or  one-third  their  normal  length,  while 
the  epiphyses  are  normal  in  size  or  increased.  The  disease  is  not 
incompatible  with  postnatal  life,  and  its  effects  on  the  pelvis  will  be 
described  in  Chapter  XXIX. 

Intra-uterine  Death  of  the  FcEtus. — The  foetus  may  die  from 
numberless  causes,  from  any  disease  or  morbid  state  either  of 
itself  or  of  the  placenta  or  membranes,  from  faults  of  development, 
probably  even  from  mere  inherent  deficiency  of  vitality,  from  any 
cause  preventing  an  adequate  supply  of  nutriment,  from  poisons 
transmitted  from  the  mother,  either  those  of  zymotic  diseases  or 
mineral  poisons,  such  as  lead  or  arsenic,  and  from  external  injuries. 
There  is  evidence  also  that  a  febrile  condition  in  the  mother  may 
of  itself  destroy  the  foetus,  apart  from  the  presence  of  any  poison. 


Diseases  of   Decidua  and  Ovum.  545 

When  the  mother  is  affected  by  fever,  the  pulse  and  temperature 
of  the  foetus  rise  in  Hke  proportion,  the  temperature  of  the  fcetus 
being  always  nearly  a  degree  above  that  of  the  mother.  Experi- 
ments on  animals  have  shown  that  artificial  elevation  of  temperature 
destroys  the  foetus  before  the  mother  dies,  and  that  a  temperature 
so  produced  in  the  mother  as  high  as  106°  is  always  fatal  to  the 
foetus.  Danger  to  the  foetus  may  be  considered  to  have  begun 
when  the  temperature  has  reached  104°.  No  doubt  in  the  great 
majority  of  instances  foetal  asphyxia,  either  acute  or  chronic,  is  the 
immediate  cause  of  foetal  death. 

Diseases  of  the  foetus  such  as  pleurisy,  pneumonia,  or  endocarditis 
may  also  occur,  apparently  from  transmission  either  of  microbic 
infection  or  of  toxins  from  the  mother.  These  may  lead  to  its 
death  either  before  or  shortly  after  birth. 

Sometimes  the  foetus  dies  without  any  obvious  cause,  and  in 
some  instances  this  occurrence  has  been  repeated  at  about  the 
same  time  of  pregnancy  in  a  number  of  successive  pregnancies,  or 
every  alternate  pregnancy.  When  a  macerated  foetus  is  exiDelled, 
evidence  of  syphilis  may  be  found  in  the  majority  of  cases,  on  a 
careful  examination  of  it,  especially  in  regard  to  the  epiphyses  of 
the  long  bones  of  the  limbs.  In  the  case  of  repeated  death  of  the 
foetus  at  about  the  same  time  of  pregnancy,  syphilis  appears  also  to 
be  the  most  usual  cause.  In  some  instances,  however,  such  a 
result  has  been  attributed  to  malnutrition  of  the  mother,  or  to 
disease  of  the  placenta  not  due  to  syphilis,  but  to  some  other  cause, 
such  as  pre-existing  endometritis.  It  has  been  recommended  in 
cases  in  which  the  foetus  has  repeatedly  died  in  the  later  months  of 
pregnancy  to  induce  premature  labour  a  little  before  the  time  at 
which  death  generally  occurs.  If  the  suspected  cause  be  syphilis, 
this  proceeding  offers  little  hope  of  success,  since  the  foetus  would 
probably  already  have  grave  visceral  lesions.  A  better  plan  is  to 
give  a  course  of  mercurial  treatment  to  both  parents  in  the  interval 
of  pregnancy,  and  to  the  mother  during  pregnancy.  If,  however, 
the  probability  of  syphilis  be  excluded,  and,  more  especially,  if 
examination  of  the  foetus  on  a  previous  occasion  has  shown  it  to  be 
in  itself  healthy,  the  plan  of  inducing  labour  some  time  after  the 
seventh  month  may  be  adopted. 

Retention  of  dead  Foetus  in  Utero  ;  Maceration,  Mummi- 
fication.— As  a  rule  the  death  of  the  embryo  or  foetus  is  followed 
by  the  expulsion  of  the  ovum  in  from  two  days  up  to  two  or  three 
weeks.  For  degenerative  changes  in  the  placenta  and  membranes 
follow  the  foetal  death  ;  the  ovum  begins  to  act  like  a  foreign  body 

M.  35 


546  The  Practice  of   Midwifery. 

and  excites  the  uterus  to  exjDel  it.  There  is  an  exception  to  this 
rule  in  the  case  of  twin  or  triplet  pregnancy.  In  this  case,  if  one 
ovum  dies,  it  is  more  usual  for  the  blighted  ovum  to  be  retained 
until  the  birth  of  the  living  child,  especially  if  the  placentae  are 
conjoined,  or  united  at  their  borders.  This  is  probably  to  be 
exjDlained  on  the  ground  that  the  degenerated  placenta  occupies  a 
relatively  small  part  of  the  interior  uterine  surface  (a  condition 
usually  the  actual  cause  of  the  death  of  the  ovum),  while  the  main 
part  of  that  surface  remains  still  in  contact  with  living  and  growing 
membranes.  In  some  cases  even  of  single  pregnancy,  a  blighted 
ovum  or  dead  foetus  may  be  retained  for  months  within  the  uterus, 
especially  if  its  death  has  taken  place  in  the  earlier  part  of  preg- 
nancy. The  cause  probably  is  either  that  the  uterine  irritability 
is  less  than  usual,  or  that  the  placenta  remains  closely  attached  to 
the  uterine  wall,  and  so  maintains  a  certain  degree  of  vitality.  Or 
these  two  causes  may  be  in  operation  together.  In  the  great 
majority  of  cases,  uterine  pains  come  on  at  what  would  have  been 
the  full  term  of  pregnancy,  if  not  before,  and  the  ovum  is  then 
expelled.  Much  more  frequently,  a  macerated  foetus  is  expelled 
before  the  end  of  the  seventh  month.  An  early  foetus  may  become 
entirely  dissolved  in  the  liquor  amnii  and  all  traces  of  it 
disappear. 

Maceration  is  the  most  usual  and  typical  change  which  follows 
the  death  of  the  fcetus.  This  is  a  slow  moist  decomposition,  but 
not  putrefaction,  in  the  jDresence  of  the  liquor  amnii,  but  with  the 
exclusion  of  air.  The  cuticle  generally  becomes  loosened,  detached 
in  large  pieces,  or  raised  in  blebs.  The  cutis  and  deeper  tissues 
are  stained  brownish-red  from  infiltration  with  blood  pigment. 
Fatty  degeneration  in  the  tissues  and  deposition  of  fat  crystals  take 
place,  especially  near  the  surface.  The  attachment  of  the  bones, 
especially  of  the  cranial  bones,  is  loosened.  The  tissues  become 
soft  and  lacerable,  and  the  whole  body  is  somewhat  swollen  and 
loses  its  tonicity,  so  that  it  may  be  squeezed  into  almost  any  shape. 
The  presentation,  in  consequence,  is  very  apt  to  be  an  abnormal 
one.  The  brain  is  converted  into  a  soft  diffluent  mass,  and  the 
viscera  eventually  lose  their  anatomical  characters.  The  tissues 
are  generally  oedematous,  and  turbid  sero-sanguineous  fluid  collects 
in  the  serous  cavities  and  in  all  the  tissues.  The  liquor  amnii 
becomes  turbid  and  greenish  or  brownish,  and  has  a  sickly  dis- 
agreeable smell,  not,  however,  that  of  putrefaction.  The  funis  is 
soft,  smooth,  and  lacerable,  and  is  stained  brownish-red,  like  the 
cutis.  The  placenta  is  pale,  yellowish,  and  friable,  showing  fibrous 
degeneration   and   fatty   changes,  but   the  difficulty  of  exchiding 


Diseases  of   Decidua  and   Ovum. 


547 


ante-mortem  changes  must  always  be  remembered.  If  the  mem- 
branes become  ruptured,  and  air  and  germs  obtain  an  entry, 
putrefaction  generally  takes  place  quickly  within  a  few  days. 

Mummification  is  a  term  applied  to  a  drier  form  of  change  in  the 
fcetus.  It  occurs  especially  in  twin  pregnancy,  when  the  ovum  has 
become  blighted,  and  is  to  be  ascribed  partly  to  the  gradual  death 
of  the  fcetus  from  deficient  blood  supply,  partly  to  the  effect  of 
pressure.  The  tissues  are  here  found  shrunken  instead  of 
oedematous.  The  skin  lies  almost  immediately  on  the  bones,  only 
scanty  muscles  intervening,  and  the  areolar  tissue  seems  to  have 
disappeared  (Fig.  295).  The  placenta  is  pale,  small,  and  tough. 
The  liquor  amnii  is  absorbed,  and  the  foetus  is  closely  enveloped 
by  the  membranes.  The  tissues  also  are 
comparatively  tough,  and  the  foetus  looks  as 
if  it  had  been  shrivelled  up  by  being  kept 
in  spirit.  The  foetus  is  generally  found 
squeezed  up  or  flattened,  and,  in  the  latter 
case,  has  been  termed  "foetus  jiapyraceus  " 
or  "  compressus.'"  A  similar  result  may 
sometimes  happen  in  single  pregnancy  if 
the  foetus  dies  gradually  from  such  a  cause 
as  torsion  or  stenosis  of  the  funis,  the  liquor 
amnii  being  scanty.  Possibly  also  it  may 
occur  if  the  liquor  amnii  escapes  by  a  small 
opening,  without  entry  of  air,  and  the 
placenta  retains  some  vitality  by  adhesion 
to  the  uterine  wall. 

Symptoms  and  Diagnosis  of  the  Death  of 
the   Foetus. — The   breasts   are   arrested    in 

their  development,  become  flaccid,  and  soon  shrink.  In  the  later 
months,  however,  the  sign  of  the  death  of  the  foetus  may  be  a 
temporary  secretion  of  colostrum  or  milk,  like  that  which  follows 
its  expulsion,  followed  later  by  recession  of  the  breasts.  When 
ultimately  the  dead  foetus  is  expelled,  as  a  rule  no  mammary 
changes  occur.  Other  reflex  symptoms,  such  as  nausea  and 
vomiting,  which  depend  ujjon  the  growth  of  the  uterus,  often 
cease,  while  the  mother  may  complain  of  a  feeling  of  general 
malaise,  epigastric  pain,  a  feeling  of  weight  in  the  abdomen,  or 
irritability  of  bladder  or  rectum.  The  enlargement  of  the  abdomen 
and  uterus  ceases,  except  in  the  case  of  vesicular  mole.  The  symp- 
toms and  signs  which  are  found  in  the  earlier  months  of  pregnancy 
in  the  case  of  a  blighted  ovum  or  carneous  mole  have  already  been 
described  (sec  p.  522).     Sometimes  a  subjective  feeling  of  coldness 

35—2 


Fig.  295.— Shrunken  foetus 
after  retention  in  utero. 


548 


The   Practice  of   Midwifery. 


in  the  site  of  the  uterus  is  given  as  a  sign  of  death  of  the  foetus, 
especially  when  pregnancy  is  somewhat  more  advanced.  This  is 
not  much  to  be  relied  upon.  The  ovum  cannot  of  course  become 
colder  than  surrounding  parts,  although  it  ceases  to  be  a  source  of 
heat. 

In  the  later  months,  the  mere  apparent  cessation  of  fcetal  move- 
ments must  not  be  taken  as  evidence  of  the  child's  death,  for  it 
may  frequently  remain  quiet  for  a  considerable  time.  Nor  is 
reliance  to  be  placed  upon  failure  to  hear  the  foetal  heart  upon  a 


Fig.  296. — Contents  of  cyst,  in  Dr.  Oldham's  case  of  missed  labour. 

particular  occasion.  If,  however,  toward  the  end  of  pregnancy  a 
sldlled  observer  has  previously  heard  the  foetal  heart  easily,  and 
afterwards  fails  to  hear  it  on  repeated  trials,  while  movements  also 
can  no  longer  be  detected,  the  presumption  of  the  death  of  the  foetus 
is  considerable.  In  general,  before  making  a  positive  diagnosis,  it 
is  desirable  to  wait  until  arrest  in  the  enlargement  of  the 
uterus  and  recession  in  the  development  of  the  breasts  become 
manifest. 

Treatment. — The  treatment  in  the  earlier  months  of  pregnancy 
has  already  been  described  (see  p.  522).  In  the  later  months,  when 
the  diagnosis  has  been  made  absolute  by  sufficient  lapse  of  time, 
and  especially  if  there  is  any  sanguineous  or  offensive  discharge, 


Diseases  of   Decidua  and  Ovum.  549 

the  membranes  may  be  punctured,  and  tents  or  hydrostatic  dilators 
used  afterwards,  if  required. 

Missed  Labour. ^The  term  "  missed  labour  "  has  been  applied 
to  cases  in  which,  with  or  without  the  occurrence  of  labour  pains  or 
of  a  false  labour,  the  feet  us  has  died  and  then  has  been  retained  for 
weeks  or  even  months  in  iitero.  The  condition  must  be  distin- 
guished carefully  from  cases  of  extra-uterine  gestation  or  of  preg- 
nancy in  the  undeveloped  cornu  of  a  unicornate  uterus.  The 
foetus  usually  undergoes  maceration  or  mummification,  or  may  be 
converted  into  adipocere,  but  if  the  membranes  rupture  and  in- 
fection occurs,  suppuration  of  the  uterine  contents  may  take  place. 

In  the  classical  case  of  Dr.  Oldham,^  who  first  introduced  the 
term,  the  foetus  became  disorganised,  and  converted  into  a  mass  of 
bones  and  adipocerous  matter  (see  Fig.  296),  portions  of  which 
were  discharged  or  removed  through  the  os  uteri  for  the  course  of 
three  months  from  the  date  of  the  fall  term  of  pregnancy.  The 
woman  then  died,  and  the  mass  was  found  in  an  imperfect  cyst 
formed  by  the  abdominal  parietes  and  the  posterior  uterine  wall, 
the  anterior  uterine  wall  having  been  apparently  worn  through. 
This  case  is  therefore  open  to  the  interpretation  that  an  extra- 
uterine sac  may  have  ruptured  into  the  uterus,  although  Dr.  Oldham 
recorded  that  he  felt  the  foetus  in  utero  during  life.  In  a  case 
reported  by  the  author,^  which  had  at  first  been  diagnosed  as  one  of 
missed  labour,  a  watery  discharge  escaped  through  the  cervix  uteri, 
two  months  after  the  date  of  full  term.  After  dilatation  by  a  tent, 
the  foetus  was  felt  presenting  by  the  finger  passed  through  the  cervix 
at  an  opening  resembling  the  internal  os.  The  woman  died,  and 
the  foetus  was  found  to  be  in  an  extra-uterine  sac  which  had  formed 
an  opening  just  at  the  convexity  of  the  bend  in  a  retroflexed  uterine 
canal. 

A  sufficient  number  of  cases  have  now  been  recorded  and  verified 
by  operation  to  make  it  certain  that  the  condition  of  missed  labour 
does  occur. ^  While  the  retained  placenta  may  undergo  some 
increase  in  size  from  degenerative  changes  after  death  of  the  foetus, 
no  definite  proof  has  so  far  been  produced  that  it  can  grow  in  the 
true  sense  of  the  term. 

The  symptoms  of  this  condition  are  those  due  to  the  death  of  the 
fa'tus,  and  the  diagnosis  may  be  extremely  difficult,  esj^ecially  if  the 
foetus  has  been  dead  some  time  and  the  liquor  amnii  has  all  become 

1  Proc.  I'ath.  Soc,  ]Mr,-i7,  First  Seswion,  p.  103. 

2  Trans.  Obst.  Soc.  r.oridon,  187.o,  Vol.  XVII. ,  p.  170. 

8  V.  Franque,  Zeitschr.  f.  Geb.  u.  Gyn.,  18!)7,  \id.  37,  s.  277. 


550  The  Practice  of   Midwifery. 

absorbed.     If  septic  infection  and  suppuration  occur  the  patient 
runs  a  considerable  risk  of  general  septicaemia. 

The  treatment  of  missed  labour,  if  in  any  case  it  is  established 
that  the  fcetus  is  certainly  in  the  uterus,  is  to  dilate  the  cervix  by 
laminaria  tents  and  hydrostatic  dilators,  and  to  empty  the  uterus 
with  the  patient  under  an  anaesthetic,  the  portions  of  the  fcetus 
being  removed  by  the  fingers,  or  by  whatever  forceps  are  found  most 
conveniently  to  grasp  them. 


Chapter  XXIIL 

ACCIDENTAL  COMPLICATIONS  OF  PREGNANCY. 

The  following  are  diseases  which  occur  independently  of  preg- 
nancy, but  which  are  of  such  a  nature  that  they  have  a  special 
influence  on  pregnancy,  or  pregnancy  upon  them. 

Chronic  Cardiac  Diseases. — The  physiological  changes  in  the 
heart  which  result  from  pregnancy  have  already  been  explained. 
The  increased  volume  of  the  blood  and  increased  arterial  tension 
cause  some  dilatation,  especially  of  the  left  ventricle.  This  leads  to 
compensatory  hypertrophy,  which  may  proceed  as  far  as  actually 
to  improve  the  circulation  (see  p.  166).  When,  however,  chronic 
valvular  disease  exists,  the  case  is  different.  A  degree  of  com- 
pensation by  hypertrophy  may  then  have  been  attained,  sufficient 
to  maintain  the  circulation  under  ordinary  circumstances.  But 
when  a  further  dilatation  and  increase  of  tension  is  produced  by 
pregnancy,  the  powers  of  nutrition  may  be  unable  to  resjDond  by 
producing  a  further  compensation  by  hypertrophy.  This  is  rendered 
more  probable  by  the  fact  that  a  certain  degree  of  anaemia  is  not 
uncommon  in  pregnancy,  and  that  this  anaemia  may  be  carried 
to  a  pathological  degree,  especially  when  vomiting  or  other  diges- 
tive disturbances  occur.  The  embarrassment  of  the  lungs,  and 
consequent  tendency  to  inflammatory  changes  in  them,  which 
result  from  the  cardiac  disease,  are  also  increased  by  the  inter- 
ference with  respiration  due  to  the  abdominal  distension.  A  still 
further  strain  is  placed  upon  the  diseased  heart  by  the  process 
of  labour.  This  is  proved  by  the  fact  that,  in  many  recorded  cases, 
patients  who  have  survived  pregnancy  and  parturition  have 
succumbed  within  two  or  three  weeks  after  delivery.  During  the 
labour  itself,  the  heart's  action  often  becomes  very  irregular,  and 
the  patient  cyanotic. 

When  the  heart  disease  is  at  all  grave,  pregnancy  therefore 
proves  a  very  serious  complication.  Out  of  31  cases  collected  by 
Angus  Macdonald,^  17,  or  55  per   cent.,   proved  fatal.     Many  of 

1  The  Bearing  of  Chronic  Disease  of  the  Heart  upon  Pregnancy,  Parturition,  and 
Childbed,  London,  1878. 


552  The  Practice  of   Midwifery. 

these  cases,  however,  were  specially  severe.  Abortion  or  premature 
labour  frequently  comes  on  spontaneously,  when  symptoms  are 
grave,  and  this  occurrence,  in  several  cases,  anticipated  the  execu- 
tion of  the  physician's  resolve  to  induce  labour.  According  to 
Macdonald,  cases  of  mitral  regurgitation  prove  the  least  grave, 
those  of  mitral  contraction  the  most  grave.  This  is  probably 
explained  hj  the  fact  that,  in  the  latter  case,  the  tension  which 
generally  produces  dilatation  and  hypertrophy  of  the  left  ventricle  is 
all  expended  upon  the  left  auricle,  and  thence  thrown  back  upon 
the  lungs  and  right  heart.  In  aortic  regurgitation,  the  symptoms 
were  severe,  but  were  generally  relieved  after  delivery,  if  the 
patient  had  passed  safely  through  that  stage. 

The  prognosis  depends  rather  upon  the  condition  of  the  heart 
muscle  than  upon  the  nature  of  the  valvular  lesion.  If  the  heart 
muscle  is  healthy  and  compensation  present  the  danger  is  small, 
whereas  if  the  heart  muscle  is  degenerated  and  compensation  want- 
ing the  danger  is  very  considerable.  The  maternal  mortality  in  all 
cases  is  about  12  to  14  per  cent. 

The  fatal  result  is  generally  due  to  over-distension  of  the  right 
side  of  the  heart  and  cardiac  paralysis,  or  to  cardiac  failure  the 
result  of  extensive  degenerative  changes  in  the  heart  muscle. 

Prophylaxis. — In  all  cases  of  chronic  heart  disease  which  jDro- 
duce  any  marked  symptoms,  such  as  dyspnoea,  palpitation,  oedema, 
or  notable  alteration  of  jnilse,  the  ph^^sician  should  advise  the 
patient  not  to  marry,  if  his  opinion  is  asked. 

Treatment. — The  general  management  of  the  cardiac  condition, 
and  treatment  by  drugs,  are  the  same  as  when  there  is  no 
pregnancy.  All  exciting  causes  of  pulmonary  complications  should 
be  especially  avoided.  In  labour,  early  assistance  by  forceps  or 
version  should  be  given,  and  bearing-down  efforts  of  the  patient 
restrained  as  much  as  possible.  A  sandbag  should  be  placed  upon 
the  abdomen  or  an  abdominal  bandage  used  to  lessen  the  risk 
from  the  sudden  fall  in  the  blood  pressure  following  on  the  birth 
of  the  child. 

Anaesthesia  may  usually  be  employed  without  any  increase  of 
danger.  Cases  undoubtedly  occur  from  time  to  time  in  which,  in 
order  to  lessen  the  strain  on  a  heart  which  shows  signs  of  yielding, 
the  induction  of  abortion  or  of  premature  labour  should  be  carried 
out.  The  physician  should,  however,  warn  the  patient  and  her 
friends  that  the  immediate  sequel  of  labour,  whether  spontaneous 
or  induced,  may  be  aggravation  of  symptoms,  since  it  must  always 
be  remembered  that  the  risk  of  death  following  upon  delivery  may 
be  greater  for  a  time  than  it  is  during  pregnancy.     Macdonald 


Accidental   Complications  of   Pregnancy.     553 

held  that  premature  labour  should  seldom  or  never  be  recom- 
mended, because  it  is  likely  to  do  greater  harm  than  good,  by 
disturbing  the  action  of  the  heart  and  the  condition  of  the  lungs. 

Acute  Endocarditis. — Acute  endocarditis  may  occur  in  preg- 
nancy as  at  other  times,  and  is  a  very  fatal  complication.  Not 
infrequently  it  happens  that,  in  consequence  of  extra  strain  in 
pregnancy,  fresh  valvular  inflammation  supervenes  upon  chronic 
disease.  This  may  take  either  the  ordinary  plastic  or  the  ulcerative 
form.  Embolism  is  then  apt  to  occur,  and  in  this  way  aj)oplexy 
and  paralysis  may  be  produced. 

Phthisis. — The  opinion  has  been  held  by  many  that  pregnancy 
acts  as  a  prophylactic  against  phthisis  in  those  predisposed  to  that 
disease.  There  is  no  evidence,  however,  that  this  is  really  the 
case  in  general.  It  may  be  true  in  some  of  those  cases  in  which 
pregnancy  appears  to  improve  the  general  health,  but  it  probably 
more  frequently  occurs  that  impairment  of  health,  from  some  of 
the  disturbances  of  pregnancy,  favours  the  onset  of  the  disease. 
The  fact  that  the  susceptibility  to  phthisis  of  unmarried  women  is 
rapidly  diminished  after  thirty  years  of  age,  while  that  of  married 
women  maintains  its  intensity  between  twenty-five  and  forty  years 
of  age,  that  is  during  the  child-bearing  period,  seems  to  show  that 
pregnancy  has  a  deleterious  effect  upon  those  disposed  to  phthisis. 
To  this  there  are  many  exceptions.  The  puerperal  state  and  lactation 
have  a  much  more  decidedly  unfavourable  influence.  As  a  rule, 
abortion  or  premature  labour  occurs  spontaneously  only  when  the 
condition  of  the  mother  is  becoming  extreme,  or  when  her  blood  is 
insufficiently  aerated.  In  the  later  stages  of  phthisis  amenorrhoea 
results,  and  pregnancy  is  not  likely  to  occur,  but  in  the  earlier  or 
quiescent  stages  of  the  chronic  form  of  the  disease  this  is  not  the 
case.  Phthisical  women  should  be  advised  not  to  marry,  both  on 
account  of  the  increased  risk  to  themselves,  the  probably  phthisical 
predisposition  of  their  children,  and  the  possible  communication 
of  contagion  to  their  husbands.  The  first  child  is  often  well 
nourished,  but  subsequent  children  are  very  likely  to  be  feeble  and 
delicate.  Labour,  in  phthisical  women,  should  receive  early  assist- 
ance by  the  use  of  forceps.  Artificial  induction  of  abortion  has 
been  performed  on  account  of  phthisis.  But  the  general  opinion 
is  that  the  influence  of  the  pregnancy  upon  the  phthisis  is  so 
uncertain  that,  as  a  rule  at  any  rate,  this  operation  is  not  justi- 
fiable. The  same  conclusion  will  apply  even  to  the  induction  of 
premature  labour. 


554  The   Practice  of   Midwifery. 

Acute  Lobar  Pneumonia. — Pneumonia,  which  in  other  respects 
has  a  close  analogy  to  zymotic  diseases,  shows  this  character  also 
in  its  relation  to  pregnancy.  Pregnancy  seems  to  afford  a  certain 
protection  against  its  onset,  but,  when  it  does  occur,  its  severity 
and  danger  are  increased.  The  gravity  of  the  disease  is  greater, 
the  further  advanced  is  the  pregnancy,  and  if  it  occurs  after  the 
sixth  month  about  50  per  cent,  of  the  mothers  die.  This  may 
partly  be  explained  by  the  interference  of  the  distended  abdomen 
with  the  descent  of  the  diaphragm  and  freedom  of  respiration, 
although  the  capacity  of  the  chest  is  not  actually  diminished,  as 
was  formerly  supposed.  Pneumonia  leads  to  abortion  in  about  one- 
third  and  to  premature  labour  in  about  two-thirds  of  the  cases. 
This  may  be  due  to  imperfect  oxj-genation  of  blood,  to  the  general 
effect  of  the  acute  disease  on  the  mother's  system,  or  to  the  death 
of  the  foetus  produced  by  the  high  temperature  (see  p.  545).  In 
the  latter  case,  delivery  may  be  delayed  until  the  acute  stage  has 
subsided.  Premature  labour,  either  induced  or  spontaneous,  renders 
the  prognosis  much  more  unfavourable.  As  will  be  explained  in 
the  chapter  on  puerperal  fevers,  there  is  some  evidence  that 
pneumonia,  existnig  before  delivery,  may  merge  into  puerperal 
septicaemia,  the  pneumococcus  behaving  as  a  septic  microbe. 

Treatment. —  Premature  labour  should  on  no  account  be  induced, 
but  the  onset  of  labour  should  be  averted  if  possible.  If  labour 
does  come  on  near  full  term,  early  aid  should  be  given  by  forceps, 
if  called  for.  Digitalis  is  often  useful  to  maintain  the  vigour 
of  the  heart,  and  generally  stimulant  treatment  is  likely  to  be 
called  for. 

Jaundice. — Jaundice  is  a  rare  affection  in  pregnancy,  but  has 
great  interest  from  the  tendency  which  exists  for  apparently  simj)le 
jaundice  to  develop  into  the  fatal  disease,  acute  yellow  atrophy  of 
the  liver.  Sometimes  such  a  development  takes  place  only  after 
delivery.  Of  seven  cases  of  jaundice  in  pregnancy  met  with  by 
Sj)iegelberg,^  two  were  cases  of  acute  yellow  atrophy. 

Simple  Jaundice. — Simple  jaundice  may  run  an  ordinary  course 
during  p>regnancy.  As  a  rule,  it  does  not  lead  to  abortion  or  pre- 
mature labour,  but  this  result  does  sometimes  happen.  The  foetus 
and  liquor  amnii  are  sometimes,  but  not  always,  stained  yellow 
with  bile  pigment. 

Acute  Atrophy  of  the  Liver.— Of  164  cases  of  acute  atrophy 
of  the  liver,  66  occurred  in  pregnant  women.     The  disease  may 

1  Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  English  translation,  1887,  Vol.  I.,  p.  357. 


Accidental  Complications  of   Pregnancy.     555 

occur  as  early  as  the  sixth  week  of  pregnancy,  but  is  commoner 
towards  the  later  months.  It  generally  begins  like  simple  jaundice  ; 
then  grave  constitutional  symptoms  supervene,  elevation  of  pulse 
and  temperature,  headache,  severe  and  repeated  vomiting, 
haemorrhages,  delirium,  coma,  and  death  usually  within  a  week 
from  the  onset  of  the  attack.  A  diminution  in  the  size  of  the 
liver  may  be  detected. 

Pathological  Anatomy. — The  liver-cells  are,  in  great  measure, 
destroyed  by  parenchymatous  degeneration.  The  degenerative 
changes  usually  begin  in  the  periphery  of  the  lobule,  but  in  some 
cases,  and  constantly  in  those  cases  occurring  as  a  sequel  to  the 
toxaemic  vomiting  of  pregnancy,  the  change  begins  in  the  centre  of 
the  lobule.  There  is  also  degeneration  of  the  muscles,  especially  of 
that  of  the  heart.  Degeneration  of  the  kidney-cells  has  also  been 
described  in  some  cases.  Abortion  or  premature  labour  often 
comes  on,  and  the  foetus  and  liquor  amnii  are  found  stained  with 
bile  pigment.  The  presence  of  crystals  of  leucin  and  ty rosin  in  the 
urine,  which  is  scanty,  high-coloured,  and  of  high  specific  gravity, 
is  characteristic.  There  is  also  an  alteration  in  the  relation  between 
the  ratios  of  urea  and  ammonia  in  the  urine,  the  percentage  of  the 
latter,  which  normally  is  about  5  per  cent.,  rising  to  as  much  as 
12  to  37  per  cent.  The  most  probable  explanation  of  this  is  that 
the  ammonia  is  carried  out  of  the  body  in  combination  with  organic 
acids,  and  therefore  cannot  be  turned  into  urea,  of  which  less  is 
excreted. 

Causation. — It  is  generally  believed  that  the  disease  is  due  to 
some  form  of  toxaemia,  but  the  exact  mode  of  origin  of  the  poison 
is  obscure.  In  some  cases  severe  mental  shock  or  mental  distress 
appears  to  be  an  exciting  cause.  According  to  Spiegelberg,  the 
symptoms  of  acute  atrophy  are  often  preceded  by  haemorrhage  from 
the  uterus  or  other  parts,  which  may  have  a  depressing  influence. 
In  very  rare  instances  an  apparent  epidemic  of  acute  atrophy  of  the 
liver  in  pregnant  women  has  been  recorded.  Of  44  recent  cases  of 
acute  yellow  atrophy  no  less  than  9  in  pregnant  women  occurred 
in  districts  in  which  epidemic  attacks  of  jaundice  appear  relatively 
common. 

There  are  three  main  views  as  to  the  nature  of  this  disease  :  that 
it  is  a  primary  disease  of  the  liver,  that  it  is  a  general  disease  with 
secondary  involvement  of  the  liver,  and  that  it  is  a  rare  form  of 
infective  disease.  The  resemblance  between  cases  of  acute  yellow 
atrophy  and  cases  of  malignant  jaundice  is  extremely  close,  and 
there  can  be  no  doubt  but  that  they  are  both  due  to  some  virulent 
organic  poison  of  unknown  nature  acting  especially  upon  the  liver. 


55^  The   Practice  of   Midwifery. 

Pregnancy  would  aid  in  the  production  of  such  poison,  since  both 
the  kidneys  and  the  liver  are  then  apt  to  have  their  functions 
deranged  because  of  the  increased  work  thrown  upon  them,  and  the 
interference  with  the  circulation.  The  Jaundice  is  due  to  a  catarrhal 
condition  of  the  finest  bile  ducts,  and  is  no  doubt  produced  by  the 
excretion  in  the  bile  of  the  poison  which  damages  the  liver-cells. 
The  condition  of  the  liver  in  acute  atrophy  is  similar  to  that 
produced  by  phosphorus  poisoning,  but  in  the  latter  condition  the 
liver  is  usually  enlarged  and  not  atrophied,  and  the  percentage  of 
fat  is  much  higher,  from  3  to  30  per  cent.,  as  compared  with  the 
normal  5  per  cent,  found  in  acute  yellow  atrophy.^ 

Treatment. — Simple  jaundice  in  pregnancy  may  be  treated  in  the 
ordinary  way.  Moderate  use  of  purgatives  and  diuretics  is  desirable. 
Acute  atroj)hy  when  once  developed  is  almost  hopeless,  although 
cases  of  recovery  have  been  recorded  even  in  pregnancy.^  Saline 
transfusion  may  be  employed  and  intestinal  antiseptics  given,  while 
the  administration  of  sodium  bicarbonate  is  indicated  in  view  of 
the  high  percentage  of  ammonia  in  the  urine  and  the  fact  that  the 
autolysis  of  the  liver  is  favoured  by  the  acid  reaction  of  the  tissues. 
If  in  simple  jaundice  haemorrhages  occur,  or  the  urine  is  albuminous 
or  deficient  in  urea,  or  there  are  any  other  grave  constitutional 
symptoms,  such  as  coma  or  mental  aff"ection,  indicating  a  danger 
that  acute  atrophy  may  supervene,  the  question  of  induction  of 
premature  labour  or  abortion  should  be  considered. 

Diabetes. — Diabetes  is  another  disease  affected  by  pregnancy.  It 
is  to  be  remembered  that  physiological  glycosuria  occurs  in  the 
puerperal  woman,  and  it  appears  proved  that  a  certain  number  of 
pregnant  women  have  glycosuria  not  due  to  the  resorption  of 
lactose.  Cases  have  been  recorded  in  which  diabetes  has  recurred 
in  successive  pregnancies,  and  has  been  absent  during  the  intervals, 
as  is  sometimes  the  case  with  albuminuria.  Not  infrequently 
23regnancy  occurs  in  a  diabetic  patient,  and  runs  its  course  undis- 
turbed ;  but  generally  the  diabetes  is  aggravated,  and  the  complica- 
tion is  of  grave  import  both  to  mother  and  child.  Of  cases  collected 
by  Matthews  Duncan,^  namely,  22  pregnancies  in  15  mothers,  4 
ended  fatally  during  the  puerperal  period,  premature  labour  having 
been  induced  in  one  of  these.  Hydramnios  was  frequent,  and  in 
one  case  sugar  was  found  in  the  liquor  amnii.  In  7  out  of  19  cases 
the  child  died  during  the  pregnancy,  after  reaching  viable  age,  and 
in  2  more  it  died  a  few  hours  after  birth. 

1  W.  Hunter,  Clifford  AUbutt's  System  of  Med.,  Vol.  IV.,  Part  1,  p.  115. 

2  Creed  and  Scott  Skirving,  Austral.  Med.  Gaz.,  1888-89,  Vol.  VIII.,  p.  259. 
8  Trans.  Obst.  Soc.  London,  1882,  Vol.  XXIV.,  p.  256. 


Accidental   Complications  of   Pregnancy.     557 

Of  19  cases  collected  by  Stengel/  of  whom  16  were  multiparas, 
ten  of  the  mothers  died  either  at  the  time  of  labour  or  within  a 
few  weeks. 

Treatment  should  be  the  same  as  if  the  patient  were  not  preg- 
nant, but  the  labour  should  not  be  allowed  to  continue  too  long. 

Pyelonephritis  of  Pregnancy. — In  a  small  number  of  cases  of 
pregnancy  a  condition  of  pyelonephritis  develops  about  the  fourth 
or  fifth  month  which  rapidly  clears  up  after  the  birth  of  the  child, 
and  appears  to  be  dependent  directly  upon  the  presence  of  the 
foetus  in  utero.  Dilatation  of  one  or  of  both  ureters  commonly  is 
present,  most  frequently  of  the.  right  one,  and  as  a  rule  there  is  no 
antecedent  cystitis.  The  dilatation  of  the  ureter,  which  is  usually 
situated  about  one  inch  from  its  entrance  into  the  bladder,  has  been 
assumed  to  be  due  to  the  pressure  of  the  foetal  head,  but  this  cause 
obviously  cannot  come  into  play  as  early  as  the  middle  of  pregnancy, 
and  it  is  possibly  due  to  some  constriction  of  the  ureter,  swollen  as 
a  result  of  the  pregnancy  as  it  passes  through  the  ureteral  canal  in 
the  cellular  tissue  at  the  base  of  the  broad  ligament.  The  chief 
feature  of  the  disease  is  the  presence  of  pus  in  the  urine  without 
cystitis,  accompanied  by  fever  and  pain  in  the  loins  or  in  the  back. 
In  the  majority  of  cases  the  organism  present  is  the  bacillus  coli. 
The  infection  occurs  probably  by  the  blood  stream,  possibly  by  the 
lymphatics.  As  a  rule  the  patient  recovers  with  treatment  during 
the  iDregnancy,  or  the  condition  clears  up  after  delivery.  Only  very 
exceptionally  is  there  any  question  of  the  induction  of  premature 
labour. 

Bronchocele. — Cases  have  been  observed  in  which  abronchocele 
has  occurred  for  the  first  time  or  increased  during  pregnancy.  It  is 
a  question  how  far  the  causation  depends  upon  the  increased  vascular 
tension  of  pregnancy,  and  how  far  upon  a  reflex  nervous  influence. 
A  temporary  increase  of  the  swelling  of  the  thyroid  is  apt  to  be 
produced  by  the  straining  of  labour ;  but  the  enlargement  generally 
subsides  to  a  great  extent,  though  not  altogether,  after  delivery, 
while  great  improvement  or  recovery  may  result  in  a  case  of 
exophthalmic  goitre  from  pregnancy. 

Heemorrhages. — Women  who  are  liable  to  haemorrhages  have 
this  liability  increased  by  the  increased  vascular  tension  of  preg- 
nancy. In  some  cases,  also,  the  deteriorated  quality  of  the  blood 
may  have   an   influence.      Thus   haemoptysis   occasionally  occurs 

1   Univ.  of  Pcnnsylv.  Med.  Bulletin,  October,  1903. 


558  The  Practice  of   Midwifery. 

during  pregnancy;  and  in  that  condition  it  has  not  the  same 
significance  as  at  other  times  in  indicating  the  probable  existence 
of  phthisis.  Again,  epistaxis  and  bleeding  from  the  alimentary 
canal,  especially  from  the  rectum  and  stomach,  are  not  uncommon. 
Cerebral  haemorrhage,  producing  paralysis,  sometimes  occurs,  but 
this  is  more  especially  associated  with  albuminuria.  Distended 
varices  sometimes  rupture  on  the  surface,  and  pelvic  hematocele, 
from  rupture  of  a  vessel  near  the  uterus,  has  occasionally  been 
recorded. 

Appendicitiso— Although  pregnancy  cannot  be  said  to  predispose 
to  an  attack  of  appendicitis,  yet  a  previously  existing  attack  is 
likely  to  be  greatly  aggravated  during  pregnancy,  and  very  serious 
symptoms  may  arise,  while  the  danger  of  the  condition  is  certainly 
increased. 

The  congestion  of  the  pelvic  organs  and  the  frequency  of  severe 
constipation  would  appear  to  favour  the  occurrence  of  suppuration. 
The  synii^toms  will  be  the  same  as  those  of  an  attack  occurring 
apart  from  pregnancy,  but  the  diagnosis  may  be  extremely  difficult, 
and  the  attack  is  very  likely  to  be  regarded  as  one  of  pelvic  peritonitis 
or  of  pyelonephritis,  while  in  the  puerperium  a  perforative  peritonitis 
may  be  thought  to  be  due  to  septic  infection.  Eecent  observations 
tend  to  show  that  abortion  or  premature  labour  does  not  occur  as 
frequently  as  might  be  anticij)ated,  but  during  labour  or  after 
delivery  the  rupture  of  an  encapsuled  collection  of  pus  may  be 
brought  about  by  the  contraction  or  the  shrinking  of  the  uterus. 
At  the  same  time,  in  some  cases,  the  presence  of  the  enlarged 
uterus  helps  to  shut  in  a  collection  of  pus. 

In  all  cases  in  which  an  acute  attack  occurs  in  the  early  months 
of  pregnancy  an  operation  should  be  performed.  In  the  later 
months  the  question  is  a  more  difficult  one  to  decide,  and  the 
danger  of  the  complication  is  much  greater.  Even  at  this  period 
of  pregnancy,  however,  in  view  of  the  great  risk  the  patient  runs 
during  labour  and  the  puerperium,  operative  interference  is  indicated, 
and  on  the  whole  it  appears  best  not  to  induce  labour,  as  has  been 
recommended  by  some  writers,  before  operating.  As  a  general  rule 
the  case  should  be  treated  as  if  the  patient  were  not  pregnant. 

Oyarian  Tumours — Ovarian  tumours  of  small  size  may  not 
interfere  with  the  course  of  pregnancy  or  parturition,  provided  they 
do  not  occupy  the  pelvis.  If  the  tumour  is  of  considerable  size, 
the  complication  is  a  serious  one.  The  tension  may  become  so 
great  before  the  end  of  pregnancy,  that  vital  functions  are  interfered 


Accidental  Complications  of   Pregnancy.     559 

with.  Other  dangers  also  exist,  the  tumour  may  rupture  under  the 
influence  of  pressure,  or  the  presence  of  the  enlarged  uterus  may 
cause  twisting  of  the  pedicle,  or  interference  with  its  circulation, 
with  resulting  necrotic  and  inflammatory  changes  in  the  tumour. 
The  obstruction  to  labour  which  an  ovarian  tumour  occupying 
the  pelvis  may  cause  will  be  considered  hereafter  (see 
Chapter   XXVIII.). 

Treatment. — In  cases  where  an  ovarian  tumour  is  found  to 
complicate  pregnancy  as  a  general  rule  ovariotomy  should  be  per- 
formed without  delay.  The  risk  of  the  operation  is  very  small. 
Thus  McKerron^  records  299  ovariotomies  during  pregnancy  with  a 
mortality  of  only  3"3  per  cent.,  and  in  219  cases  collected  by 
Graefe,^  operated  upon  since  1902,  the  maternal  mortality  was  only 
0'47  per  cent.,  and  the  pregnancy  continued  uninterruptedly  in 
84  per  cent.  The  only  exception  to  the  rule  of  immediate  operation 
might  be  the  case  where  it  was  thought  advisable  in  the  later 
months  of  pregnancy  to  wait  until  the  child  was  certainly  viable,  but 
in  such  a  case  it  must  always  be  borne  in  mind  that  the  presence  of 
the  large  uterus  may  prove  a  serious  obstacle  to  the  operation. 

Fibroid  Tumours  of  the  Uterus. — Although  fibroid  tumours 
of  the  uterus  are  often  associated  with  sterility,  yet  pregnancy  may 
occur,  especially  if  the  tumours  are  subperitoneal.  The  tumours 
then  generally  increase  in  size  with  the  growth  of  the  uterus,  and 
may  in  some  cases  undergo  atrophy  with  the  involution  of  the 
uterus.  A  difficulty  of  diagnosis  may  arise  during  pregnancy,  and 
the  suspicion  may  be  raised  of  the  presence  of  extra-uterine  foeta- 
tion  on  account  of  the  irregularity  of  the  tumour  containiDg  the 
foetus.  In  other  cases  the  fibroid  tumour  becomes  so  softened 
during  pregnancy  as  to  render  its  recognition  difficult,  or  it  may  be 
mistaken  for  an  ovarian  tumour.  When  the  fibroids  are  external, 
pregnancy  and  parturition  are  often  undisturbed ;  when  they  are  in 
the  wall  of  the  uterus,  there  is  a  tendency  to  malpresentations  of 
the  foetus,  inertia  of  the  uterus,  and  to  post-partum  haemorrhage. 

In  cases  where  the  fibroid  tumour  is  attached  to  the  posterior 
wall  it  may  become  impacted  in  Douglas'  pouch  and  cause  incarcera- 
tion of  the  uterus,  and  in  the  case  of  a  pedunculated  subserous  fibroid 
torsion  of  the  pedicle  may  occur  with  acute  symptoms.  At  times 
during  the  progress  of  the  pregnancy  the  tumours  are  the  seat  of 
much  pain,  but  in  the  great  majority  of  cases  this  passes  off  with 
rest  in  bed. 

1  K.  G.  McKeiTon,  rre^'iancy,  Labour,  and  Childbed  with  Ovariau  Tumour,  1903. 

2  Graefc,  Zeitschr.  f.  Gob.  u.  Gyn.,  1905,  Bd.  50,  p.  499. 


560  The  Practice  of   Midwifery. 

Diagnosis. — This  may  be  easy  or  difficult.  Small  tumours  may 
be  mistaken  for  fcetal  parts,  or,  if  very  soft,  not  recognised  at  all. 
In  the  case  of  multiple  fibroid  tumours  causing  considerable  and 
general  enlargement  of  the  uterus,  the  recognition  of  an  early 
jDregnancy  may  be  almost  impossible,  and  a  correct  diagnosis  often 
only  can  be  made  by  watching  the  growth  of  the  tumour  and 
waiting  for  the  signs  of  fcetal  life.  In  a  large  number  of  cases 
uteri  have  been  removed  and  then  found  to  contain  a  fcetus.  Soft 
subserous  tumours  may  be  mistaken  for  a  dermoid  ovarian  cyst, 
and  this  mistake  is  especially  likely  to  occur  if  the  pedicle  becomes 
twisted.  Eepeated  examinations  should  be  made  at  different  times, 
and  in  all  cases  of  doubt  the  patient  should  be  watched  and  the 
signs  of  pregnancy  carefully  looked  for. 

Treatment.  —  Interference  during  pregnancy  is  very  rarely 
required,  and  should  only  be  carried  out  if  serious  symptoms 
arise  from  the  pressure  of  the  tumour  or  from  degenerative  or 
inflammatory  changes  occurring  in  it. 

The  induction  of  abortion  or  premature  labour  should  not  be 
practised,  and  whenever  possible  the  case  should  be  allowed  to  go 
to  full  term,  and  then  whatever  treatment  may  be  necessary 
carried  out  (see  Chapter  XXVIL). 

Surgical  Operations. — The  effect  of  a  surgical  operation  in 
pregnancy  varies  greatly  according  to  the  susceptibility  of  the 
woman  to  reflex  influence.  In  one  case  the  extraction  of  a  tooth 
may  bring  on  labour;  in  another  ovariotomy,  or  amputation  of 
the  thigh,  may  produce  no  such  result.  But  after  serious  opera- 
tions abortion  or  premature  labour  follows  in  a  considerable 
proportion  of  cases  (according  to  Cohnstein's  statistics,  in  45'5  per 
cent.).  The  tendency  appears  to  be  greater  in  the  third  and  fourth 
and  in  the  last  two  months,  less  in  the  middle  months.  The  cause 
may  be  reflex  influence,  or,  less  frequently,  the  fever  following  the 
operation.  Operations  on  the  vagina  or  in  the  neighbourhood  of 
the  uterus  are  more  likely  to  interrupt  pregnancy.  Such  operations 
are  also  likely  to  be  attended  with  considerable  haemorrhage.  Preg- 
nancy does  not  appear  to  be  unfavourable  to  the  recovery  of  the 
patient,  but  the  puerperal  state  is  so.  It  is  therefore  unfavourable 
if  premature  labour  follows  very  quickly  upon  a  severe  operation. 

It  is  better  to  defer  ox)erations  not  of  an  urgent  character  until 
after  delivery,  unless  the  condition  for  which  the  operation  is 
required  is  aggravated  by  pregnancy,  or  is  likely  to  cause  difficulty 
in  delivery.  So  far  as  possible,  no  serious  operation  should  be 
performed  during  the  puerperal  period. 


Accidental  Complications  of   Pregnancy.     561 

Ague.- — The  relation  of  malarial  fever  to  pregnancy  is,  in  some 
degree,  similar  to  that  of  zymotic  diseases.  It  is  met  with  but 
rarely,  but  when  it  does  occur  it  is  aggravated.  Latent  malarial 
infection  may  also  become  again  active  during  pregnancy.  This  is 
more  likely  to  happen  in  the  puerperal  state,  at  which  time  fever, 
ascribed  to  malaria,  is  relatively  common  in  malarial  districts. 
At  this  time  also,  the  character  of  the  fever  is  modified;  instead 
of  being  intermittent,  it  becomes  remittent,  and  the  paroxysms 
become  irregular.  Malarial  fever  not  uncommonly  leads  to  abor- 
tion or  premature  delivery.  In  some  cases  there  has  been  evidence 
of  its  communication  to  the  fcetus,  which  may  die  before,  or  soon 
after,  delivery  ;  but  in  fifteen  cases  recorded  by  Whitridge  Williams^ 
in  no  instance  did  the  foetus  show  signs  of  the  disease,  although  in 
all  cases  its  blood  was  carefully  examined. 

Syphilis. — The  effects  of  syphilis  upon  the  fcetus  and  the 
placenta  have  already  been  described.  Syphilis  may  be  inherited 
from  either  parent,  or  both,  even  if  the  disease  exists  only  in  a 
latent  condition.  In  the  case  of  untreated  syphilis,  syphilitic 
children  may  be  procreated  for  ten  years  or  more,  the  intensity  of 
the  infection  diminishing  with  the  lapse  of  time. 

If  a  pregnant  woman  acquires  syphilis,  the  local  manifestations 
in  the  neighbourhood  of  the  genital  organs  are  more  severe  than 
usual,  in  consequence  of  the  hyperaemia  of  those  parts.  The  con- 
stitutional disease  is  generally  mild.  A  woman  impregnated  by  a 
husband  who  has  latent  syphilis,  may  acquire  the  disease  for  the 
first  time  from  the  foetus.  In  this  case  the  symptoms  are  very 
mild,  and  only  those  manifestations  which  are  generally  late  ones 
may  be  shown.  Some  authorities  deny  the  communication  of 
syphilis  from  the  foetus  to  the  mother,  and  vice  versa.  But  what  is 
known  as  Colles'  law  is  admitted  as  a  general  rule,  although 
exceptions  have  been  recorded.  This  is,  that  a  woman  is  never 
infected  by  nursing  her  own  child  suffering  from  hereditary 
syphilis,  though  another  woman  is  likely  to  be  so,  and  though  she 
may  never  have  shown  signs  of  the  disease.  It  is  not  certain 
whether  this  implies  that  all  such  mothers  have  had  symptoms  so 
slight  that  they  have  been  overlooked,  or  whether  the  mother  receives 
from  the  fcetus  a  modified  form  of  the  disease  so  that  there  are  no 
noticeable  symptoms,  or  that  the  mother  absorbs  from  the  foetus 
some  antitoxin  and  so  acquires  for  herself  immunity  either  partial 
or  complete.     But  in  any  case  it  proves  that  the  syphilitic  poison 

1   W.  WilliiirriH,  CJbMtctrics,  li>08,  p.  485. 

M.  30 


562  The  Practice  of  Midwifery. 

affects  the  mother.  In  other  cases  again  a  syphihtic  mother 
bears  an  a^Dparently  healthy  child,  which  is  however  immune  to 
syhilis,  cannot  be  infected  by  its  mother,  and  whose  blood  gives  a 
jDOsitive  result  with  Wasserman's  reaction.  When  a  pregnant 
woman  acquires  syphilis,  the  foetus  may  have  symptoms  similar  to 
those  of  the  hereditary  disease.  It  is  probable,  if  the  infection  takes 
place  after  the  seventh  month  of  pregnancy,  that  the  foetus  generally 
escapes.  But  Hutchinson^  has  recorded  cases  in  which  the  mother 
was  infected  within  the  last  few  weeks  of  pregnancy,  and  in  which 
the  child,  after  birth,  had  symptoms  like  the  ordinary  hereditary 
disease. 

Treatment. — If  syphilis  is  acquired  during  j^regnancy,  mercurial 
treatment  throughout  the  remainder  of  pregnancy  is  of  importance 
for  the  sake  of  the  child,  as  well  as  for  that  of  the  mother.  The 
formula  given  at  p.  578  may  be  used. 

Tetanus. — Tetanus  during  pregnancy  has  been  observed  chiefly 
in  the  earlier  months,  and  pregnant  women  appear  to  have  an 
increased  liability  to  the  disease,  at  any  rate  during  the  first  half 
of  pregnancy.  It  has  generally  followed  some  minor  operation,  or 
some  manipulation  in  connection  with  the  induction  of  abortion. 
The  gravity  of  the  disease  is  the  same  as  that  of  puerperal 
tetanus. 

Tetany. — Tetany  is  a  disease  which,  when  it  occurs,  usually 
develops  in  the  later  months  of  pregnancy  and  may  last  during 
lactation.  The  prognosis  is  almost  invariably  favourable,  but  a 
fatal  result  has  been  recorded.  It  may  recur  in  successive  preg- 
nancies. Tetany  is  especially  likely  to  occur  during  the  spring  in 
epidemics  in  certain  localities,  and  is  a  disease  of  extremely  local 
distribution.  Thus  it  is  very  rare  in  London,  but  not  uncommon  in 
Vienna  and  Heidelberg. 

Zymotic  Diseases. 

Any  zymotic  disease  may  occur  during  pregnancy.  But  in 
general  the  pregnant  woman  appears  to  be  less  liable  than  others 
to  the  outbreak  of  a  zymotic  disease,  while,  on  the  other  hand,  the 
puerjDeral  woman  is  much  more  liable.  This  rule  does  not,  how- 
ever, ap]3ly  equally  to  all  diseases.  It  is  most  marked  in  the  case 
of  scarlatina,  and  probably  least  marked  in  that  of  small-pox. 
Any  severe  zymotic  disease  is  rendered  more  grave  by  pregnancy, 

1  Medical  Times  and  Gazette,  1878. 


Accidental    Complications  of   Pregnancy.     563 

especially  in  the  later  months,  but  still  more  so  by  the  puerperal 
state.  Most  zymotic  diseases  are  apt  to  lead  to  premature  labour 
or  abortion.  There  are  three  elements  which  may  tend  toward 
this  result  :  first,  the  death  of  the  fcetus  from  the  high  tempera- 
ture ;  secondly,  the  effect  of  the  severity  of  the  disease  upon  the 
mother ;  thirdly,  the  effect  on  the  mother  of  the  special  zymotic 
poison  concerned.  That  the  third  element  is  actually  operative 
is  proved  by  the  special  tendency  of  small-pox  to  produce  pre- 
mature labour,  even  when  it  runs  a  mild  course,  and  when  the 
child  is  born  alive.  The  mode  of  operation  is,  in  some  cases,  the 
production  of  haemorrhage  in  the  uterus  or  placenta.  The  puerperal 
state  being  much  more  unfavourable  than  that  of  pregnancy,  the 
longer  abortion  or  premature  labour  is  deferred  the  better  it  is 
for  the  mother.  Labour  should  not  therefore  be  induced  in  any 
case,  although,  in  small-pox,  when  the  child  is  viable,  induction 
might  give  it  a  better  chance  of  surviving. 

Variola — Small-pox  has  been  observed  in  pregnancy  oftener 
than  most  zymotic  diseases.  Confluent  or  unmodified  small-pox 
is  very  dangerous  to  the  mother,  and  proves  fatal  in  the  majority 
of  cases.  It  tends  to  assume  the  haemorrhagic  form,  and  specially 
to  cause  uterine  haemorrhage.  In  almost  all  cases  it  leads  to 
abortion  or  premature  labour  and  the  death  of  the  foetus.  Modi- 
fied or  discrete  small-pox  generally  runs  a  favourable  course,  but 
even  this  leads  to  abortion  or  premature  labour  in  most  cases, 
although  not  so  constantly  as  the  more  severe  disease. 

In  a  certain  proportion  of  cases,  but  not  invariably,  the  foetus  is 
affected  by  the  disease  in  utero.  Sometimes  it  is  born  with 
pustules  upon  it.  In  other  cases,  when  it  is  delivered  at  a  later 
stage  the  scars  of  pustules  are  visible.  When  premature  labour 
occurs  early  in  the  disease,  the  child  may  become  affected  a  few 
days  after  delivery.  Sometimes,  although  not  apparently  affected, 
the  child  dies  shortly  after  birth.  In  other  cases,  the  child,  which 
has  shown  no  trace  of  the  disease,  is  found  to  be  insusceptible  to 
vaccination.  Cases  even  have  been  recorded  in  which  it  has  been 
supposed  that  the  child  was  affected  by  the  disease  in  utero,  or  very 
shortly  after  birth,  during  epidemics  of  small-pox,  although  the 
mother  did  not  suffer  from  it,  or  in  which  one  of  twins  in  utero  took 
the  disease  from  the  mother  while  the  other  escaped. 

Vaccination  during  pregnancy  appears  to  run  its  course  as  usual. 
In  an  epidemic  of  small-pox,  therefore,  pregnant  women,  who  have 
not  Ijeen  revaccinated,  should  undergo  that  operation.  Vaccina- 
tion should  not  Ije  performed  very  shortly    after  delivery,    since 

86—2 


564  The  Practice  of  Midwifery. 

even  a  very  slight  zymotic  poison  may  then  have  an  unfavourable 
influence. 

Scarlatina. — Scarlatina  is  very  rare  during  pregnancy,  especially 
as  compared  with  its  frequency  during  the  few  days  after  delivery. 
According  to  some,  the  incubation  may  be  prolonged  for  weeks  and 
months  during  pregnancy,  and  the  outbreak  only  take  place  after 
delivery  (see  section  on  Scarlatina  in  Chapter  XXXIX.).  Mild 
cases  of  scarlatina  may  run  a  favourable  course.  If  the  fever  is 
high,  abortion  or  premature  labour  generally  follows,  and  then  the 
danger  is  greatly  increased,  as  in  ordinary  puerperal  scarlatina. 
It  has  been  inferred  that  the  disease  may  be  conveyed  to  the  foetus 
in  utero,  because  the  child,  at  or  shortly  after  birth,  has  sometimes 
shown  desquamation  of  the  skin  or  other  sequelse  of  the  disease. 

Measles. — Measles  rarely  occurs  in  pregnancy.  Usually  the 
disease  runs  an  ordinary  and  mild  course.  But  cases  have  been 
recorded  in  which  it  has  been  unusually  severe,  tending  towards  a 
hsemorrhagic  type,  or  complicated  by  pneumonia.  In  such  cases 
premature  labour  or  abortion  frequently  follows.  The  child  has 
been  born  with  the  eruption  of  measles. 

Erysipelas. — Erysipelas  is  not  very  common  in  pregnancy.  It 
does  not  seem  to  prove  specially  dangerous,  unless  premature 
labour  is  the  consequence.  There  is  then  a  serious  risk,  since  the 
streptococcus  of  erysipelas  is  very  closely  allied  to,  if  indeed  it  is 
not  the  same  as,  the  streptococcus  pyogenes  of  septicaemia;  but 
this  may  be  averted  if,  by  strict  antiseptic  precautions,  conveyance 
of  the  microbes  to  the  vagina  can  be  prevented.  The  risk  is  much 
increased  if  the  erysipelas  is  in  the  vicinity  of  the  genital  canal. 
Even  in  cases  of  erysipelas  limited  to  the  head  and  face,  the  foetus 
at  the  time  of  birth  has  been  affected  both  by  cutaneous  erysipelas 
and  by  septicaemia  or  pyaemia.  It  is  possible,  therefore,  for  septic 
poison  to  be  transmitted  to  the  genital  canal  through  the  blood  (see 
Chapter  XXXIX.). 

Enteric,  Typhus,  and  Relapsing  Fevers. — All  these  diseases 
are  rare  during  pregnancy,  especially  in  the  later  months.  Enteric 
fever  leads  to  premature  labour  or  abortion  in  the  majority  of  cases. 
The  interruption  of  pregnancy  generally  follows  at  the  time  when 
temperature  ranges  the  highest,  and  the  prognosis  is  rendered  more 
grave  in  consequence,  although  as  a  rule  the  delivery  occurs  quite 
normally.      Severe  haemorrhage  is  apt  to  follow  after  abortion  in 


Accidental   Complications   of   Pregnancy.     565 

the  earlier  months,  and  it  has  been  thought  that  the  prognosis  of 
the  disease  is  on  this  account  more  grave  at  that  time  than  in  the 
later  months.  Transmission  of  enteric  fever  to  the  foetus  has  been 
proved  by  the  finding  of  bacilli  in  it  after  death.  Eelapsing  fever, 
according  to  Murchison  and  Zuelzer,^  leads  to  interruption  of  preg- 
nancy in  almost  every  case.  Weber,^  however,  at  St.  Petersburg 
found  this  happen  in  only  28  out  of  63  cases.  Typhus  fever  is  less 
apt  to  lead  to  premature  labour  or  abortion  than  either  of  the  other 
two,  and  its  course  is  not  so  much  modified  by  pregnancy  as  that  of 
many  zymotic  diseases. 

Cholera. — It  does  not  appear  that  jDregnancy  affords  any  notable 
protection  against  cholera.  Accounts  differ  as  to  whether  the 
mortality  of  the  disease  is  increased  by  the  complication.  It  is 
said  to  be  both  more  frequent  and  more  fatal  in  the  later  months. 
Interruption  of  pregnancy  follows  in  a  considerable  proportion  of 
cases,  and  in  others  it  is  probably  only  prevented  by  the  early  fatal 
termination.  Haemorrhage  into  the  uterus  is  apt  to  occur,  and  is 
one  of  the  causes  of  abortion. 

1  Monatschr.  f.  Geburtshiilfe,  Vol.  XXX. 

2  Berlin.  Klin.  Wochenschr. ,  Vol.  VII. 


Chapter  XXIV. 
PREMATURE  EXPULSION  OF  THE  OVUM. 

The  term  abortion  or  miscarriage  is  applied  to  premature  expul- 
sion of  the  ovum  when  this  occurs  before  the  time  when  the  child 
becomes  viable,  or  capable  of  possibly  surviving.  After  that 
date,  the  term  premature  labour  is  used.  The  point  of  demarcation 
between  the  two  may  be  taken  as  the  end  of  the  sixth  calendar 
month,  or  about  183  days,  although  there  is  practically  but  little 
chance  of  the  child  being  reared,  if  born  before  the  end  of  the 
twenty-eighth  week,  or  196  days.  A  distinction  is  sometimes  made 
between  abortion  and  miscarriage,  the  term  abortion  being  used  in 
the  first  two  or  three  months  of  pregnancy,  before  the  placenta  is 
formed,  and  the  term  miscarriage  from  the  time  when  the  placenta 
is  formed  up  to  the  date  when  the  child  is  regarded  as  viable.  It  is 
better,  however,  to  consider  the  terms  abortion  and  miscarriage  as 
sjmonjans,  since  no  distinct  boundary  between  the  two  can  be  assigned, 
and  women  themselves  generally  prefer  the  word  miscarriage  to  the 
word  abortion. 

Premature  expulsion  of  the  ovum  is  one  of  the  commonest  of  the 
morbid  occurrences  of  pregnancy.  On  an  average,  every  woman 
who  has  borne  children  and  reached  the  limit  of  the  child-bearing 
age  has  had  at  least  one  abortion  or  premature  labour.  The  pro- 
portion of  abortions  to  full-term  deliveries  has  been  estimated  as 
being  as  much  as  one  to  five,  and  multiparas,  as  might  be  expected, 
are  more  subject  to  them  than  primiparse. 

The  attachment  of  the  ovum  to  the  uterine  wall  is  less  firm  in  the 
early  months  of  pregnancy  before  the  complete  formation  of  the 
placenta.  Hence  it  is  within  the  first  four  months  of  pregnancy, 
and  especially  in  the  third  month,  that  abortions  are  most  common. 
Within  the  first  few  weeks  of  pregnancy  many  abortions  pass 
altogether  unrecognised,  or  only  suspected.  A  woman  goes  a  few 
days,  or  two  or  three  weeks,  beyond  the  expected  time  of  menstrua- 
tion ;  then  haemorrhage  occurs,  resembling  a  menstrual  period  rather 
more  profuse  than  usual,  and  an  ovum  may  escape  unobserved.  If 
shreds  of  decidua  are  detected,  these  show  only  a  slightly  greater 
development  than  the  shreds  of  menstrual  decidua  sometimes  passed 
in  menstruation  without  any  conception.     It  is  therefore  impossible 


Premature  Expulsion  of  the  Ovum.        567 

to  estimate  accurately  the  relative  frequency  of  abortions  within  the 
first  two  months.  Abortions  positively  diagnosed  occur  most  fre- 
quently between  the  sixth  and  the  sixteenth  week.  This  fact  may 
be  explained  not  only  from  early  abortions  being  often  undetected, 
but  partly  also  on  the  ground  that  some  causes  of  abortion,  such  as 
retroflexion  or  fibroid  tumour  of  the  uterus,  only  begin  to 
operate. when  the  ovum  and  uterus  have  reached  a  certain  size,  and 
that  the  various  diseases  of  the  embryo  or  membranes  which  may 
lead  to  abortion  require  a  certain  time  for  their  development  before 


Fig.  297. — Usual  mechanism  o£  abortion         FiG-.  298.— Mechanism  of  abortion  in  the 
within  the  first  two  months  of  preg-  early  months,  with  inversion  of  the 

nancy.  decidua  vera. 

the  embryo  is  destroyed,  or  the  membranes  so  much  altered  as  to 
excite  the  uterus  to  expulsion. 

Mechanism  of  Abortion. — Within  the  first  two  months  of  preg- 
nancy the  ovum  is  most  frequently  expelled  entire  together  with 
the  decidua  vera,  decidua  capsularis,  and  the  rudimentary  placenta 
(see  Fig.  297).  The  whole  ovum  is  either  expelled  surrounded  by  the 
decidua  vera,  or  it  becomes  separated  at  the  placental  site  and  is 
extruded  first,  dragging  after  it  the  decidua  vera,  which  is  thus 
stripped  off  the  uterine  wall  and  is  inverted,  the  mechanism 
reHCTnbh"ng    that    of    Schultze's    method    of    separation    of    the 


568 


The  Practice  of  Midwifery. 


placenta  (see  Fig.  298).  In  other  cases  the  decidua  reflexa  or  capsu- 
laris  is  ruptured,  and  the  ovum,  surrounded  by  the  amnion  and  the 
rudimentary  chorion,  is  expelled,  leaving  behind  in  utero  the  greater 
part  of  the  decidua  basalis  undergoing  development  into  the  placenta 
and  the  decidua  vera  and- capsularis  (see  Fig.  299).  These  subse- 
quently come  away  as  a  whole  or  broken  up  into  fragments. 

In   the   course   of  the   third  month,  the   ovum  may  either  be 


Fig.  299. — Mechanism  of  abortion  in 
cases  where  the  greater  part  of  the 
decidua  basalis,  together  with  the 
decidua  vera  and  capsularis,  is  left 
in  idero. 


Fig.  300. — Mechanism  of  abortion,  the 
foetus  expelled  in  the  intact  amnion. 


ruptured  in  its  expulsion  or  not,  according  to  circumstances, 
rupture  becoming  more  probable  as  the  month  proceeds.  If 
rupture  takes  place,  retention  of  the  incipient  placenta  is  more 
likely  to  occur.  It  is  possible,  however,  for  the  amnion  containing 
the  embryo  to  be  expelled  entire,  the  umbilical  cord  breaking  off  at 
its  attachment  to  the  surface  of  the  placenta  and  the  latter,  together 
with  the  chorion,  being  retained  in  utero.  In  other  cases  again  the 
embryo  enclosed  in  the  amnion  and  the  chorion  may  come  away 


Premature  Expulsion  of  the  Ovum.        569 

entire,  leaving  a  part  of  the  placenta  in  utero.  After  the  end  of  the 
third  month,  the  amnion  is  usually  ruptured  from  the  effect  of  the 
uterine  contractions,  and  the  liquor  amnii  escapes.  Then  the 
embryo  is  expelled  first,  and  the  placenta  is  discharged  afterwards, 
as  in  labour  at  full  term. 

The  later  the  stage  of  pregnancy  reached,  the  more  nearly  does 
the  process  resemble  that  of  ordinary  labour.  In  the  middle  months 
of  pregnancy,  after  the  placenta  has  been  formed,  but  before  the 
formation  of  that  layer  of  open  meshwork  which  facilitates  its 
separation  from  the  uterine  wall  (see  p.  79),  the  separation  of  the 
placenta  is  much  more  difficult,  and  the  uterine  action  is  often 
insufficient  to  effect  it  completely.  Hence  either  the  whole  or  a 
portion  of  the  placenta  is  liable  to  be  retained  for  a  longer  or 
shorter  period,  especially  if  attached  in  one  of  the  tubal  angles  of  the 
uterus,  unless  removed  artificially.  It  is  from  the  tenth,  and  more 
especially  from  the  twelfth,  up  to  about  the  twentieth  week  that  this 
specially  close  union  exists  between  the  placenta  and  the  uterine 
wall,  and  hence  an  abortion  within  these  limits  of  time  is  more 
likely  to  lead  to  grave  results  than  either  before  or  after. 

Cervical  Abortion. — In  primiparse  the  external  os  often 
presents  a  good  deal  of  rigidity,  and  after  the  separated  ovum  has 
been  expelled  into  the  dilated  cervical  canal  it  may  be  retained 
there  for  some  time  behind  a  partly  dilated  external  os,  the 
uterine  contractions  no  longer  having  any  effect  upon  it,  forming 
the  so-called  cervical  abortion. 

Causation. — The  uterine  contractions,  which  expel  the  ovum 
prematurely,  are  excited  either  by  a  cause  acting  directly  upon  the 
nervous  centres,  or  one  which  calls  out  reflex  action,  or  by  a  com- 
bination of  the  two.  Both  the  excitability  of  the  nerve  centres 
and  the  tendency  to  congestion  of  the  uterus  are  greatest  at  the 
epochs  which  would  have  been  menstrual  periods  if  pregnancy  had 
not  occurred,  and  hence  abortion  is  especially  likely  to  happen  at 
these  dates.  Different  women  also  vary  immensely  in  the  ease 
with  which  abortion  can  be  excited.  The  difference  depends  chiefly 
upon  the  degree  of  irritability  of  the  nervous  system,  but,  to  some 
extent  also,  upon  the  firmness  of  attachment  of  the  ovum  to  the 
uterus.  Thus  cases  are  on  record  in  which  women  have  fallen 
out  of  windows  from  a  height  sufficient  to  fracture  their  limbs, 
and  pregnancy  has  been  undisturbed.  Ovariotomy  and  various 
operations  upon  the  cervix  uteri  have  been  performed,  nitric  acid 
has  been  applied  to  the  interior  of  the  uterus  in  the  early  weeks 


570  The  Practice  of  Midwifery. 

of  pregnancy,  without  abortion  following.  Pregnancy  has  even 
established  and  maintained  itself  until  discovered,  notwithstanding 
the  wearing  of  an  intra-uterine  stem.  On  the  other  hand,  with 
some  women,  any  slight  mental  or  physical  disturbance,  even  the 
seeing  a  mouse  or  a  sj)ider,  appears  to  be  sufficient  to  cause 
abortion.  Frequently  both  a  predisposing  and  an  exciting  cause 
can  be  assigned ;  and,  in  the  presence  of  a  predisposing  cause,  the 
exciting  cause  may  be  of  the  most  trivial  character. 

When  once  the  uterine  contractions  have  caused  dilatation  of 
the  cervix  uteri  to  a  certain  extent,  and  have  pressed  down  the 
ovum  sufficiently  to  bulge  into  it,  the  process  of  abortion  goes  on 
automatically,  like  that  of  labour,  and  resembles  labour  on  a  small 
scale.  The  reflex  irritation  caused  by  pressure  of  the  partially 
detached  ovum  upon  the  cervix,  keeps  up  the  rhythmical  discharge 
of  energy  from  the  nerve  centres. 

The  most  important  classification  of  the  causes  of  abortion  is 
the  division  into  those  causes  which  affect  the  ovum  or  uterus  and 
those  which  act  directly  upon  the  mother.  In  the  former  class  are 
comprised  most  of  the  morbid  conditions  which  have  already  been 
described  among  the  diseases  of  pregnancy.  The  subdivisions  of 
this  class  are  the  following  : — 

(1)  Primary  morhid  conditions  of  the  Joetus,  especially  those  leading 
to  its  death. — If  the  foetus  dies  from  any  cause,  its  death  is  followed 
by  degenerative  changes  in  the  chorion  or  placenta,  which  no 
longer  continues  in  such  active  vital  connection  with  the  uterine 
wall.  The  ovum  then  begins  to  act  as  a  foreign  body,  and  sooner 
or  later  excites  the  uterus  to  expel  it.  The  production  of  extra- 
vasations of  blood  between  the  ovum  and  the  uterine  wall  is  often 
an  intermediate  step.  As  already  mentioned,  the  expulsion  generally 
takes  place  within  a  few  weeks.  Disease  or  malnutrition  of  the 
foetus,  even  without  causing  its  death,  may  also  be  associated  with 
similar  changes  in  the  membranes,  and  lead  in  the  same  way  to 
abortion.  Among  the  causes  leading  to  the  death  or  malnutrition 
of  the  foetus  must  be  reckoned  imperfect  fertility  on  the  part  of 
either  or  both  parents.  Conception  followed  by  abortion  may  thus 
be  a  stage  on  the  way  to  complete  sterility.  Syphilis  is  one  of  the 
most  frequent  and  important  causes  leading  to  abortion  through 
death  of  the  foetus,  as  well  as  through  disease  of  the  foetal  mem- 
branes, and  it  often  produces  this  effect  in  successive  pregnancies. 
In  the  case,  therefore,  of  repeated  abortions,  without  other  manifest 
cause,  special  inquiry  should  always  be  made  for  any  history  or  sign 
of  syphilis  in  either  parent.  If  none  such  can  be  found,  a  diagnosis 
may  sometimes  be  made  by  examination  of  the  foetus  (see  p.  541). 


Premature  Expulsion  of  the  Ovum.        571 

(2)  Primary  morbid  conditions  of  the  amnion,  chorion  or  decidua 
(see  pp.  510 — 550). — These  may  either  first  cause  the  death  of  the 
foetus,  or  may  directly  lead  to  abortion  by  irritating  the  uterus. 
Those  morbid  conditions  which  lead  to  haemorrhage,  and  consequent 
separation  of  chorion  or  placenta,  are  of  special  importance. 
Haemorrhages  into  and  white  infarcts  of  the  placenta  are  also 
frequent  causes.  Besides  morbid  conditions  produced  by  disease, 
separation  of  placenta  and  haemorrhage  often  arise  from  mechanical 
causes,  especially  in  cases  of  placenta  praevia.  Among  these  may 
be  mentioned  shocks,  blows,  excessive  coitus,  the  use  of  instruments 
for  the  induction  of  criminal  abortion,  violent  muscular  exertion, 
and  even  the  effect  of  coughing,  vomiting,  or  straining  at  stool. 

(3)  Morbid  conditions  of  the  uterus. — These  may  be  displacement, 
especially  retroversion  and  retroflexion  (see  p.  496),  inflammation 
of  the  whole  substance  of  the  uterus,  the  presence  of  fibroid  or  other 
tumours,  or  fixation  by  peritoneal  adhesions. 

Causes  affecting  the  mother  directly  form  the  second  main  class. 
Certain  drugs,  called  oxtyocics,  have  more  or  less  power  of  exciting 
contractions  of  the  uterus,  and  by  this  means  may  cause  abortion. 
Those  most  efficacious  appear  to  be  ergot,  and  quinine  in  large 
doses  (ten  grains  or  more).  Digitalis  in  large  doses  has  perhaps  a 
similar  effect.  Savin  and  cantharides  have  also  been  taken 
criminally  with  this  object,  and  have  sometimes  had  the  desired 
effect.  All  these  drugs  are  very  uncertain  in  their  action,  unless 
there  is  a  predisposition  to  abort.  When  ergotism  is  produced  by 
the  poisonous  effects  of  ergot  of  rye,  eaten  in  bread,  abortion  may 
result. 

All  acute  febrile  diseases  tend  to  cause  abortion.  The  poison 
of  certain  zymotic  diseases  has,  however,  a  special  tendency  to 
produce  this  effect,  apart  from  the  degree  of  fever,  apparently  by  its 
influence  on  the  nerve  centres.  Of  these,  small-pox  and  pneumonia 
are  marked  examples.  With  this  effect  of  a  zymotic  poison  may 
be  compared  the  similar  effect  of  other  poisons,  such  as  lead, 
excess  of  carbonic  acid  in  the  blood  from  asphyxia,  whether  due  to 
mechanical  cause  or  heart  or  lung  diseases,  and  the  poison  which 
exists  in  the  blood  in  renal  disease.  In  the  last  case  abortion  or 
premature  labour  may  be  produced  directly,  as  well  as  through 
death  of  the  ffjetus.  Of  mineral  poisons,  lead  has  been  most 
frequently  noted  as  a  cause  of  abortion,  generally  through  its 
leading  to  the  death  of  the  fcetus.  It  appears  to  be  capable  of 
producing  this  result  even  by  acting  in  a  remote  way  through  the 
father.  For  it  has  been  recorded  that,  when  workmen  have  suffered 
from  lead  poisoning,  their  wives  have  been  specially  liable  to  abort. 


572  The  Practice  of  Midwifery. 

Apart  from  any  special  poison,  expulsion  of  the  ovum  is  apt  to 
occur  in  any  very  grave  disease  of  the  mother,  especially  as  a  fatal 
issue  is  approaching.  It  happens  also  sometimes  from  extreme 
malnutrition,  as  in  times  of  famine,  or  in  excessive  vomiting  of 
pregnancy.  Other  general  states  of  the  system,  such  as  heart 
disease,  or  cirrhosis  of  liver,  may  act  by  producing  hyperemia  of 
the  decidua  and  consequent  extravasation  of  blood. 

Causes  acting  through  the  Nervous  System. — Abortion  is  often 
produced  by  some  sudden  or  violent  emotion,  such  as  fright,  grief, 
anxiety,  shock,  hearing  bad  news,  or  seeing  some  startling  sight. 
Such  emotional  causes  are  sj^ecially  operative  either  as  exciting 
causes,  when  there  is  already  some  predisposing  cause  at  work,  or 
in  women  of  highly  sensitive  and  neurotic  disposition.  Other 
causes  produce  a  reflex  effect  through  the  impressions  upon 
peripheral  nerves.  Thus  continuing  to  suckle  an  infant  after 
pregnancy  has  recurred  may  lead  to  abortion,  suckling  having  a 
well-known  tendency  to  set  up  uterine  contractions.  In  the  same 
way  is  to  be  explained  the  occasional  effect  of  severe  pain,  such 
as  toothache,  of  violent  purgatives,  of  any  surgical  operation,  such 
as  even  the  extraction  of  a  tooth,  but  more  especially  of  operations 
in  the  neighbourhood  of  the  uterus,  of  vaginal  syringing,  or 
distension  of  the  vagina  by  a  plug  or  india-rubber  dilator. 

It  has  been  sujDposed  that  in  some  cases  a  habit  of  aborting  at 
about  the  same  date  in  successive  pregnancies  has  become  estab- 
lished. There  seems  to  be  no  positive  proof  of  the  possibility  of 
this,  and  it  is  probable  that  in  most  such  cases  there  has  been 
some  persistent  cause,  such  as  syphilis,  or  endometritis,  or  uterine 
displacement,  which  would  naturally  lead  to  abortion  at  about  the 
same  date  of  pregnancy. 

Examination  of  the  ovum  will  sometimes  reveal  the  cause  of  the 
abortion  in  the  shape  of  degenerative  changes  in  the  chorion  or 
decidua,  or  signs  of  syphilis  in  the  fcetus. 

In  the  early  months  the  commonest  causes  of  abortion  may  be 
said  to  be  endometritis  and  retroversion  of  the  uterus,  and  in  the 
later  months  syphilis  and  chronic  Bright's  disease. 

Symptoms  and  Course  of  Abortion. — The  earliest  symptom 
of  abortion  is  usually  uterine  haemorrhage.  For  if  the  starting- 
point  of  the  process  is  uterine  contraction,  the  contraction  leads 
to  a  partial  detachment  of  the  ovum,  and  consequent  rupture  of 
vessels,  before  the  escape  of  the  liquor  amnii,  and  generally  before 
the  contraction  is  manifestly  felt  as  pain.  If,  on  the  other  hand, 
the    starting-point    is     extravasation    of    blood    into     the    foetal 


Premature  Expulsion  of  the  Ovum.        573 

membranes,  some  of  the  blood  generally  breaks  through  into  the 
decidual  cavity,  and  escapes  externally  through  the  cervix.  The 
bleeding  may  at  first  be  slight  and  intermittent,  but  is  increased 
in  quantity  when  uterine  contractions  become  active,  and  the  ovum 
begins  to  be  more  completely  sejDarated,  and  forced  down  into  the 
cervix.  Clots  of  considerable  size  are  generally  passed  before  the 
ovum  itself  is  expelled.  The  bleeding  may  continue,  continuous  or 
intermittent,  for  some  days  before  the  pains  come  on.  In  rare 
cases  it  may  last  even  for  weeks  before  ending  in  abortion.  Loss 
of  blood  is  generally  greater  after  the  second  month,  when  the 
cervix  has  to  be  dilated  to  a  considerable  size  before  the  ovum  can 


Fig.  301. — Foetus  expelled  entire  with  the  membrane  and  placenta  at  the  7th  month. 
(Univ.  Coll.  Hosp.  Med.  School  Mus.) 

pass.  It  may  then  be  sufficient  to  cause  syncope,  and  reduce  the 
patient  to  extreme  anaemia,  but  rarely  proves  fatal.  This  is  especially 
likely  to  occur  when  the  uterus  contains  a  hydatidiform  mole, 
or  when  degenerative  changes  or  fibromyomata  are  present  in  its 
walls. 

Within  the  first  two  months  the  pains  of  expulsion  may  not  be 
very  different  from  those  of  dysmenorrhoea.  The  later  the  stage 
of  pregnancy,  the  more  do  the  pains  resemble  those  of  labour  at 
term.  Cases  of  abortion  commencing  with  intermittent  pains, 
due  to  uterine  contraction,  and  leading  to  haemorrhage  only  in  the 
later  stage,  are  rarer  than  those  in  which  the  hemorrhage  is  the 
first  symptom.     They  are  generally  cases  which  occur  somewhat 


574  The  Practice  of  Midwifery. 

later  in  pregnancy ;  within  the  first  two  months,  haemorrhage 
almost  always  occurs  at  the  commencement.  In  premature  labour, 
or  in  abortion  when  pregnancy  has  nearly  reached  the  sixth  month, 
there  is  not  necessarily  any  haemorrhage  before  the  birth  of  the 
foetus,  unless  the  starting-point  of  the  premature  expulsion  has 
been  extravasation  of  blood. 

Incomplete  Abortion. — Occasionally,  even  when  the  amnion  is 
expelled  intact,  the  incipient  placenta  remains  attached  to  the 
uterus.  This  happens  much  more  frequently  when  the  amnion  is 
ruptured,  and  the  embryo  escapes  first.  If  the  attachment  of  the 
placenta  is  too  firm  for  the  subsequent  uterine  contractions  to 
break  it  down,  the  cervix  may  close  up  again,  and  the  uterus 
become  quiescent.  Generally  contractions  recur,  and  the  mass  is 
exj)elled,  after  a  few  hours,  or  within  two  or  three  days,  but 
sometimes  it  is  retained  for  weeks,  or  even  months.  In  other 
cases  the  main  mass  of  the  placenta  is  expelled  immediately  or 
shortly  after  the  embryo,  but  some  portion  of  it  is  more  adherent, 
and  remains  in  utcro. 

The  result  of  incomplete  abortion  varies  according  to  the  firm- 
ness of  attachment  of  the  placenta  to  the  uterus.  If  there  is  close 
attachment  over  nearly  the  whole  surface,  decomposition  may  be 
averted.  There  is  then  generally  but  slight  htemorrhage  in  the 
first  stage  of  the  abortion.  Usually  some  haemorrhage  occurs, 
either  continuously  or  at  intervals,  so  long  as  there  is  placenta 
retained.  In  rare  cases,  when  the  attachment  is  very  general,  there 
is  none  at  all  for  a  considerable  time,  and  it  may  even  be  supposed 
that  pregnancy  is  continuing.  Eventually,  often  at  the  date  of  a 
menstrual  epoch,  active  uterine  contractions  come  on,  separate 
more  of  the  placenta,  and  then  there  is  increased  haemorrhage  until 
the  whole  is  either  expelled  or  artificially  removed. 

More  frequently,  the  union  of  the  placenta  is  not  close  enough 
to  preserve  its  vitality,  decomposition  occurs,  and  in  a  day  or  two 
offensive  discharge  begins.  The  placenta  is  generally  expelled 
after  a  time  piecemeal,  when  the  firmness  of  adhesion  has  been 
broken  down  by  putrefaction.  The  decomj)osition  is  much 
promoted  if  the  finger  has  been  introduced  in  futile  attempts  to 
remove  the  placenta,  and  air  thereby  admitted  to  the  uterus. 
Sometimes  a  mass  of  placental  tissue  hangs  only  by  a  small  band 
of  adhesions,  and  is  forced  down  into  the  cervix  uteri,  or  through 
the  cervix  into  the  vagina,  the  body  of  the  uterus  contracting  up 
into  small  bulk.  The  projecting  portion  of  tissue  then  most 
readily  becomes  putrid.  In  other  cases,  again,  the  portion  of 
placenta,  while  taking  a  polypoid  form,  retains  some  vitality  or  is 


Premature  Expulsion  of  the  Ovum.        575, 

preserved  from  decomposition  by  being  retained  within  the  uterus 
without  free  access  of  air  or  saprophytic  microbes,  and  often 
becomes  coated  with  fibrin,  as  well  as  infiltrated  with  clot.  Such 
a  structure  has  been  called  a  placental  'polypus  or  fibrinous  x>olypus. 
In  rare  cases  the  patient  recovers  without  any  placental  mass  ever 
making  its  appearance.  The  placenta  must,  in  such  eases,  have 
broken  down  in  shreds. 

When  decomposition  of  the  placenta  occurs,  the  patient  is  exposed 
to  the  risk  of  septic  intoxication  and  septic  infection,  as  in  the  case 
of  retention  of  portions  of  placenta  after  full- term  delivery.  The 
disease,  however,  is  not  usually  so  severe,  and  rarely  leads  to  a 
fatal  result,  although  sometimes  death  does  occur.  Frequently 
rigors  come  on  within  two  or  three  days  after  the  initial  stage  of 
the  abortion,  followed  by  high  temperature,  quick  pulse,  and  other 
constitutional  symptoms.  Pelvic  peritonitis  or  pelvic  cellulitis 
not  uncommonly  follows,  more  especially  the  former,  and  often 
-  the  foundation  is  laid  for  chronic  uterine  malady.  As  in  cases 
following  full-term  delivery,  the  disease  may  either  be  simply 
septic  intoxication,  that  is,  poisonous  effects  from  the  absorption  of 
chemical  products  of  decomposition,  or  septic  infection  proper,  in 
which  there  is,  in  addition,  the  multiplication  of  septic  organisms 
in  the  blood  or  tissues  (see  Chapter  XXXIX.).  In  most  cases  the 
symptoms  subside  quickly  after  removal  of  the  putrid  material, 
and  hence  it  may  be  presumed  that  septic  intoxication  only  is  at 
any  rate  the  m.ain  element  in  the  case.  Yery  severe  cases,  however, 
may  resemble  the  gravest  forms  of  puerperal  septicaemia,  and  be 
marked  by  diarrhoea,  vomiting,  severe  headache,  great  abdominal 
distension,  and  other  signs  of  general  septic  peritonitis.  Such 
cases  occur  especially  after  the  criminal  induction  of  abortion,  in 
which  septic  microbes  may  have  been  introduced  to  the  uterus. 

Diagnosis. — In  the  diagnosis  of  an  abortion  the  first  thing  to 
determine  is  the  existence  of  pregnancy.  Pregnancy  existing,  the 
occurrence  either  of  uterine  haemorrhage,  or  of  pains  due  to 
rhythmical  uterine  contractions,  is  invariably  a  sign  of  threatening 
abortion.  The  chief  difficulty  often  is  to  determine  whether  preg- 
nancy does  exist,  especially  if  irregular  haemorrhage  has  continued 
for  some  time.  The  diagnosis  of  pregnancy  must  be  made  by  the 
ordinary  physical  signs  of  that  condition,  especially,  in  the  early 
months,  by  the  estimation  bimanually  of  the  size,  shape,  and  con- 
sistency of  the  uterus  (see  Chapter  IX.).  A  vaginal  examination 
should  always  be  made,  the  hand  being  first  disinfected  as  in  the 
case  of  labour,  and,  if  the  os  is  found  dilated,  and  a  part  of  the 
ovum  presenting  there,  or  expelled  into   the  vagina,  the  diagnosis 


576 


The  Practice  of  Midwifery. 


will  be  undoubted,  not  only  of  threatened,  but  of  inevitable  or 
partially  completed  abortion.  The  only  thing  likely  to  be  mistaken 
for  an  ovum  is  a  soft  polypus,  or  soft  fibroid  tumour,  the  lower 
segment  only  of  which  can  be  reached  by  the  finger.  If  the 
w^hole  can  be  reached,  a  polypus  will  be  distinguished  by  having 
a  iDedicle,  which  cannot  be  separated  by  the  finger,  while  an  ovum, 
or  portion  of  ovum,  is  readily  detached. 

If  a  substance  has  been  passed  j^e?-  vaginam,  examination  of  this 
will  determine  whether  an  abortion  has  occurred  or  not,  and 
whether  the  whole  of  the  ovum  has  been  expelled.  In  the  absence 
of  an  embryo,  chorionic  villi  should  be  sought  for,  to  decide  the 
fact  of  abortion.     They  may  be  seen  most  readily  if  the  blood  is 


Fig.  302. — Ovum  expelled  in  abortion  in  third  month  ;  dr,  decidua  refiexa,  the 
front  portion  removed  to  show  interior  of  ovum  ;  dr,  decidua  vera,  showing 
orifices  of  uterine  glands  ;  c,  chorion  commencing  to  form  placenta. 


Washed  away,  and  the  mass  floated  out  in  water.  A  small  portion 
of  anything  which  resembles  villi  should  then  be  spread  out  upon 
a  slide  and  examined  with  a  low  microscopic  power.  If  decidua 
only  can  be  detected,  it  must  be  remembered  that  a  decidua  of  con- 
siderable thickness,  even  intact  enough  to  form  a  cast  of  the  whole 
uterus,  is  sometimes  passed  in  membranous  dysmenorrhoea,  and 
that  a  decidua  with  cells  like  those  of  normal  pregnancy  is  formed 
and  often  passed  in  extra-uterine  foetation. 

Generally  the  decidua  reflexa  comes  away,  covering  the  ovum,  and 
may  bring  away  with  it  a  portion  of  the  decidua  vera,  attached  to 
its  border  (Fig.  302).  Special  care  should  be  taken  to  make  sure 
that  the  embryonic  placenta  is  not  left  behind. 


Premature  Expulsion  of  the  Ovum.         577 

If  the  substance  passed  has  not  been  kept  for  examination,  doubt 
may  exist  whether  a  part  or  the  whole  of  the  ovum  is  still  retained 
in  the  uterus,  and  if  so,  whether  it  is  still  continuing  to  develop  or 
is  dead.  The  continuance  of  the  pregnancy  can  often  only  be 
determined  by  noting  the  size  of  the  uterus  and  ascertaining  at  a 
subsequent  examination  if  it  has  increased  in  size  to  a  degree 
proportionate  to  the  interval  of  time  which  has  elapsed. 

If  the  whole  still  remains,  this  will  generally  be  revealed  by  the 
size  of  the  fundus  uteri,  estimated  bimanually.  If  a  part  only  is 
retained,  the  sanguineous  discharge  will  be  excessive  in  amount, 
with  the  passage  of  clots,  or  protracted,  or  will  recur  from  time  to 
time.  The  cervix  uteri  also  is  more  likely  to  continue  patulous  if 
any  considerable  piece  of  ovum  remains  within,  and  uterine  con- 
tractions will  recur,  while  it  will  close  up  and  uterine  contractions 
will  cease  if  the  whole  has  been  evacuated.  Offensive  discharge 
generally  indicates  some  placenta  retained  and  decomposing. 

Prognosis. — A  fatal  result  from  abortion  is  comparatively  rare, 
but  does  occur  occasionally,  sometimes  from  hgemorrhage,  more 
frequently  from  the  effect  of  septic  infection.  It  is  estimated  by 
Lusk,  from  the  statistics  of  deaths  in  New  York  City,  that  deaths 
from  all  causes  after  abortion  are  nearly  as  numerous  in  proportion 
as  deaths  from  metria  after  delivery  at  full  term,  if  it  be  correct  to 
reckon  one  abortion  to  every  eight  to  ten  full-term  deliveries.  I 
have  known  abortion  in  the  third  month  not  only  end  fatally,  but 
form  the  starting-point  of  a  series  of  cases  of  fatal  puerperal 
septicaemia  in  the  practice  of  the  medical  attendant.  Death, 
however,  is  very  rare,  if  abortion  is  treated  efficiently  from  the 
outset.  Abortion  very  frequently  leaves  behind  it  chronic  uterine 
disease,  chronic  congestion  and  hypertrophy  of  the  mucous  mem- 
brane, so-called  endometritis  jjosi  ahortum,  associated  with 
subinvolution  of  the  uterus.  Several  causes  tend  to  this  result. 
First,  there  is  frequently  some  already  existing  morbid  state  of  the 
uterus,  the  cause  of  the  abortion  ;  secondly,  women  often  disregard 
an  abortion,  and  omit  to  take  sufficient  rest  and  care  afterwards ; 
and,  thirdly,  the  natural  stimulus  of  lactation  in  promoting  the 
contraction  and  thereby  the  involution  of  the  uterus  is  wanting. 

I'he  danger  of  criminal  abortion  is  very  much  greater  than  that 
of  spontaneous  abortion.  This  is  to  be  explained  partly  because 
instruments  are  often  used  by  unskilled  persons  when  the  object 
is  criminal,  partly  because  the  healthy  ovum  has  a  closer  and 
more  vascular  connection  with  the  uterine  wall,  so  that  its  separa- 
tion is  more  likely  to  be  incomplete,  or  to  be  attended  with  profuse 


578  The  Practice  of  Midwifery. 

bleeding.  Of  cases  of  criminal  abortion  which  have  been  made 
public,  the  women  have  died  in  not  less  than  half.  It  must, 
however,  of  course  be  remembered  that  the  death  of  the  woman 
is  generally  the  circumstance  which  leads  to  investigation  and 
detection,  and  that  many  other  cases  remain  undetected. 

Prophylactic  Treatment. — When  any  evidence  of  syphilis  in 
either  parent  has  been  discovered  a  prolonged  course  of  mercury^ 
should  be  given  to  both  parents  in  the  intervals  of  pregnancy,  and 
to  the  mother  throughout  pregnancy.  In  the  case  of  retroflexion 
or  retroversion  of  the  uterus  the  displacement  should  be  corrected, 
and  a  pessary  should  be  worn  up  to  about  the  middle  of  the  fourth 
month. 

With  women  who  have  already  shown  a  predisposition  to  abortion, 
and  with  neurotic  and  excitable  subjects  generally,  special  care 
should  be  taken  to  avoid  all  exciting  causes,  bodily  or  mental.  The 
care  should  be  greatest  for  the  first  four  months,  and  especially  at 
the  first  two  or  three  menstrual  epochs,  at  which  times  it  is  often 
prudent  to  keep  the  woman  in  bed  for  a  few  days,  while  in  cases 
of  habitual  abortion  without  obvious  cause  it  may  be  necessary  to 
keep  the  patient  in  bed  until  she  quickens  or  even  longer.  The 
exciting  causes  most  to  be  guarded  against  are  mental  excitement 
or  alarm  and  undue  muscular  exertion.  In  some  cases  even 
travelling  and  riding  in  a  carriage  have  to  be  given  up.  Strong 
purgatives  and  the  use  of  vaginal  syringing  either  too  vigorously 
or  with  too  hot  or  cold  water  should  also  be  avoided.  Though  it  is 
not  usual  with  the  human  race  to  give  up  coitus  during  pregnancy, 
some  women  who  are  especially  prone  to  abort  only  go  to  the  full 
term  if  they  occupy  a  separate  room  from  their  husbands  during 
pregnancy,  or  at  any  rate  for  the  first  four  months. 

When  repeated  abortion  occurs  apart  from  syphilis  or  displace- 
ment of  the  uterus,  or  exciting  causes,  the  most  probable  explanation 
is  a  chronic  endometritis.  For  this  the  most  effectual  treatment 
is  often  curetting  the  endometrium  after  dilatation. 

Treatment  of  Threatened  Abortion. — So  long  as  haemorrhage 
is  not  very  severe,  while  there  is  no  proof  of  escape  of  the  liquor 
amnii,  and  the  cervix  is  not  dilated  so  as  to  allow  the  ovum  to  be 
felt  presenting,  abortion  may  be  regarded  as  only  threatened  and 
not  inevitable,  and  an  effort  made  to  avert  it.  This  is  rarely, 
however,  successful  if  both  haemorrhage  and  rhythmical  pains  are 

i  The  following  formula  may  be  used  : — Liq.  Hydiarg.  Perchlor.  nj  Ixxx.  ;  Acidi 
Hydrochlor.  dil.  m  x. ;  Syrupi  3j. ;  Aq.  ad.  3J.  ;  ter  quotidie. 


Premature  Expulsion  of  the  Ovum.        579 

present ;  if  only  one  of  these  symptoms  exists,  the  attempt  is  much 
more  hopeful.  In  all  cases  of  threatened  abortion  the  first  necessity 
is  to  direct  that  the  patient  should  be  kept  completely  at  rest  in 
bed  and  that  any  solid  substances  passed  should  be  saved  for 
examination.  If  haemorrhage  is  at  all  considerable  the  bed-pan 
should  be  used.  The  patient  should  not  leave  her  bed,  or  be  lifted 
up  from  the  horizontal  position  for  any  purpose,  and  should  avoid 
all  movement  as  far  as  possible.  Diet  should  be  light.  Alcohol 
and  very  hot  or  cold  liquids  should  be  avoided.  If  retroversion  or 
retroflexion  of  the  uterus  is  detected  on  vaginal  examination  the 
uterus  should  be  restored,  if  possible,  by  gentle  manipulation,  in 
the  manner  previously  described  (see  p.  502).  In  general  it  is 
better  to  wait  till  the  symptoms  have  been  quieted  by  rest  and 
sedatives  before  introducing  a  pessary. 

The  drug  most  to  be  relied  on  to  check  the  action  of  the  uterus 
is  opium.  A  subcutaneous  injection  of  morphia  may  be  given  to 
start  with ;  or  Battley's  liquor  opii  sedativus  or  nepenthe  may  be 
given  in  twenty-minim  doses  for  two  or  three  doses,  and  after- 
wards in  ten-minim  doses  every  four  hours.  If  the  abortion  does 
not  become  inevitable,  the  opiate  must  be  continued  until  all 
symptoms  have  completely  subsided,  and  the  patient  should  still 
be  kept  in  bed  for  a  week  or  ten  days  afterwards.  Purgatives 
should  be  specially  avoided,  and  the  bowels  should  be  relieved, 
if  necessary,  by  enema ;  or,  when  symptoms  are  subsiding,  by 
gentle  laxatives.  An  American  preparation,  the  liquid  extract  of 
Viburnum  prunifolium,  has  been  recommended  as  having  a  special 
influence  in  averting  uterine  contractions.  It  is  given  in  drachm 
doses.  Bromide  of  potassium  is  also  sometimes  useful  in  addition 
to  opium,  or  when  opium  is  not  well  tolerated.  When  haemorrhage 
persists  for  many  days  or  weeks  consecutively  without  the  occurrence 
of  active  contractions,  and  is  sufficient  in  quantity  to  necessitate 
further  treatment,  ergot  may  be  given  in  small  doses,  such  as 
ten  or  fifteen  minims  of  the  liquid  extract,  in  combination  with 
opium.  With  this  treatment  there  is  a  certain  risk  that  the 
uterus  may  be  excited  to  expel  its  contents,  but  frequently  the 
ergot  in  such  doses  induces  only  gentle  tonic  contraction  of  the 
uterus.  As  the  drug  also  tends  to  contract  the  arteries  and 
diminish  the  force  of  the  heart,  it  may  then  be  successful  in 
bringing  about  arrest  of  haemorrhage  without  the  occurrence 
of  abortion. 

Treatment  of  Inevitable  Abortion. — Abortion  may  be  regarded 
as   inevitable,  if  the  ovum  is  felt  presenting  through  the  dilated 

37—2 


580  The  Practice  of  Midwifery, 

OS,  if  the  liquor  amnii  has,  without  doubt,  escaped,  or  if  the 
haemorrhage  is  very  excessive.  If  any  considerable  clots  have 
])een  expelled  through  the  cervix  uteri,  the  abortion  almost  always 
proves  inevitable,  but  the  pregnancy  has  been  known  to  continue 
notwithstanding.  Assuming  that  the  abortion  is  inevitable,  it 
is  to  be  remembered  that  the  process  is  to  a  certain  extent  a 
natural  one,  resembling  labour  on  a  small  scale,  and  that  inter- 
ference is  necessary  only  when  haemorrhage  is  excessive,  or  the 
evacuation  of  the  uterus  incomplete.  Within  the  first  eight  or 
ten  weeks  of  pregnancy  it  is  especially  desirable  to  avoid  premature 
or  needless  manipulation,  since  this  is  likely  to  lead  to  rupture  of 
the  ovum,  which  otherwise  may  be  expelled  intact.  After  the 
fourth  month,  also,  the  process  of  abortion  approximates  more  and 
more  to  that  of  delivery ;  there  may  be  little  or  no  haemorrhage 
before  the  birth  of  the  foetus,  and,  if  so,  no  interference  is  required 
at  that  stage. 

In  the  early  months  haemorrhage  is  rarely  very  excessive,  pro- 
vided that  the  ovum  is  expelled  entire,  as  the  ovum  itself,  in  such 
cases,  forms  a  plug  when  pressed  down  into  the  cervix.  The  ovum 
need  not  then  be  removed  by  the  finger  unless  the  whole  of  it  is 
felt  as  having  descended  into  the  vagina,  or  at  any  rate  into  the 
expanded  cervix.  If  portions  of  the  decidua  vera  remain  attached 
to  the  uterine  wall,  after  the  expulsion  of  the  intact  ovum,  they 
need  not  be  sought  for  by  the  finger,  but  may  be  left  to  break  up 
and  come  away  in  the  discharges.  When  the  liquor  amnii  escapes, 
especially  in  the  third  or  fourth  month  of  pregnancy,  there  may 
be  considerable  haemorrhage  either  before  or  after  the  expulsion 
of  the  embryo.  In  this  case  the  treatment  to  be  adopted  varies 
according  to  the  condition  of  the  cervix.  If  the  cervix  is  undi- 
lated,  and  the  ovum  out  of  reach,  the  choice  lies  between  plugging 
the  vagina,  or  introducing  a  laminaria  or  tupelo  tent  into  the  cervix 
and  adding  a  vaginal  plug.  Plugging  the  vagina  is  generally 
preferable,  since  materials  for  the  purpose  are  always  at  hand,  and 
the  risk  attendant  on  the  use  of  tents  is  thus  avoided.  The  plug 
not  only  arrests  the  bleeding,  if  properly  applied,  but  acts  as  a 
stimulus  to  uterine  contraction,  so  that  the  ovum  often  is  found 
lying  behind  it,  when  the  plug  is  removed. 

Method  of  plugging  the  Vagina. — The  vulva  having  been 
carefully  cleansed,  a  vaginal  douche  should  be  given  of  lysol  1  per 
cent,  or  some  other  antiseptic  lotion.  The  best  material  to  use  is 
sterilised  iodoform  gauze  in  long  strips.  In  the  absence  of  this 
rather  broad  strips  of  lint  or  linen  about  a  foot  long  may  be  taken, 


Premature  Expulsion  of  the  Ovum.        581 

sterilised  by  boiling,  and  either  moistened  with  some  antiseptic 
such  as  cyllin  or  lysol  *5  per  cent,  solution,  perchloride  of  mercury 
1  in  3,000,  iodised  glycerine,  or  else  dusted  with  iodoform.  Strip 
after  strip  is  then  packed  in  through  a  Sim's  sjieculum  until  the 
whole  vagina  is  firmly  plugged.  The  plug  should  not  be  left  in 
more  than  about  six  hours  unless  it  be  iodoform  gauze,  in  which 
case  it  may  be  left  in  twelve  or  even  eighteen  hours,  after  which 
time  it  may  be  reapplied  if  necessary,  and  the  vagina  should  be 
again  irrigated  with  an  antiseptic  lotion  on  its  removal. 

In  conjunction  with  the  use  of  a  vaginal  plug,  a  full  dose  of  ergot 
may  be  given  in  a  case  of  abortion  with  considerable  haemorrhage. 
The  most  effectual  and  rapid  method  is  to  give  a  subcutaneous 
injection  of  ergotin  or  ernutin,  passing  the  syringe  deeply  into 
the  gluteal  muscles.  Failing  this,  one  or  two  drachms  of  the 
liquid  extract,  or  liquor  ergotae  ammoniatus,  may  be  given  by 
mouth. 

If  the  ovum  is  not  expelled  after  two  aj)plications  of  the  vaginal 
plug,  nor  the  os  sufficiently  dilated  to  allow  it  to  be  extracted,  the 
cervix  should  be  dilated  under  anaesthesia  with  Hegar's  metal 
dilators. 

Method  of  using  Hegar's  Dilators. — The  vagina  being  first  dis- 
infected, the  patient  is  anaesthetised  and  placed  in  the  lithotomy 
position,  a  Sim's  or  Auvard's  speculum  passed,  and  the  cervix  seized 
and  drawn  down  by  a  vulsellum.  A  size  of  dilator  which  will  quite 
easily  pass  is  first  used.  Then  successive  sizes  are  passed,  up  to 
about  No.  20,  when  the  cervix  will  be  large  enough  to  admit  the 
finger.  When  there  is  much  resistance,  it  may  be  necessary  to 
spend  one,  two,  or  three  minutes  in  the  introduction  of  each. 

Method  of  using  Tents. — Laminaria  or  tupelo  tents  sterilised  by 
being  kept  in  a  saturated  solution  of  iodoform  and  ether,  or  in  an 
alcoholic  solution  of  perchloride  of  mercury  1  in  1,000,  should  be 
used.  Laminaria  tents  have  the  greater  power ;  tupelo  tents 
expand  more  quickly.  Either  may  be  smeared  with  salicylic 
cream^  or  iodoform  and  vaseline,  and  mounted  upon  a  Barnes'  tent 
introducer.  The  introducer  with  the  tent  may  then  be  passed  like 
the  uterine  sound,  without  the  use  of  a  speculum,  the  patient  lying 
in  the  left  lateral  position  ;  or  Sim's  speculum  may  be  used,  the 
cervix  being  drawn  forward  and  fixed  with  a  vulsellum.  In  case  of 
difficulty  the  latter  method  should  be  chosen.  If  the  cervix  is 
small,  a  single  tent  only  is  used  ;  if  it  is  already  somewhat  dilated, 
several  are  placed  side  by  side.      The  ends  should  project  through 

1  Salicylic  acid,  I  part ;  vaseline,  8  parts. 


5^2  The  Practice  of  Midwifery. 

the  external  os.  In  the  present  case,  the  vagina  should  be 
moderately  jjlugged  below  the  tents,  to  keep  them  m  position,  and 
aid  in  arresting  haemorrhage.  Laminaria  tents  should  not  be  left 
more  than  about  eight  hours,  tupelo  tents  not  more  than  three  or 
four  hours.  On  their  removal,  an  antiseptic  douche  should  be 
again  used.  If  dilatation  is  still  insufficient,  it  should  be  com- 
pleted with  Hegar's  dilators  under  an  anaesthetic. 

Method  of  evacuating  the  Uterus. — If  the  os  is  dilated  enough  to 
allow  the  ovum  to  pass,  or,  in  the  case  of  an  early  abortion,  to 
admit  the  finger,  the  uterus  should  be  emptied  at  once,  if  the 
haemorrhage  is  so  considerable  as  to  require  interference.  The 
manipulation  now  to  be  described  is  also  to  be  carried  out  in 
precisely  the  same  way,  if  there  is  occasion  to  remove  the  placenta 
after  escape  of  the  embryo.  Unless  pregnancy  has  been  far 
advanced  the  index  finger  only  is  to  be  introduced  into  the  uterus. 
The  great  principle  to  be  followed  is,  if  possible,  to  bring  down  the 
uterus  within  reach  of  the  finger  by  external  pressure  rather  than 
to  force  the  finger  up  to  the  uterus.  The  first  essential  is  that  the 
bladder  should  be  emptied,  and  it  is  generally  well  to  make  quite 
certain  of  this  by  passing  the  catheter.  An  anaesthetic  greatly 
facilitates  the  operation.  In  its  absence,  as  much  relaxation  as 
possible  of  the  abdominal  muscles  must  be  secured.  For  this 
j)uri3ose,  the  head  should  be  supported  by  a  low  pillow  only,  the 
shoulders  low,  the  thighs  flexed.  The  left  hand  is  then  pressed 
deej)ly  into  the  abdomen,  not  too  near  the  pubes,  so  as  to  get  behind 
the  uterus,  and  bring  the  fundus  forward  close  behind  the  uf)per 
margin  of  the  symphysis  pubis.  It  is  of  the  utmost  importance  that 
the  uterus  should  always  be  brought  into  this  position,  as  in  this 
way  alone  is  it  possible  to  reach  the  fundus  of  the  uterus  when  the 
pregnancy  is  at  all  advanced.  If  the  uterus  can  once  be  got  into 
this  position,  it  is  generally  possible  to  evacuate  it  without  intro- 
ducing more  than  a  single  finger  into  the  vagina,  and  to  get  the 
finger  quite  up  to  the  fundus  by  the  time  that  the  evacuation  is 
complete.  In  introducing  the  finger,  the  cervix  is  drawn  somewhat 
forward  by  the  tip  of  the  finger  hooked  into  it,  while  the  fundus  is 
pressed  downward  by  the  external  hand. 

If  possible,  the  finger  is  passed  behind  and  above  the  ovum  or 
placenta.  The  flexor  surface  of  the  finger  then  sweeps  the  retained 
mass  so  far  as  possible  as  a  whole  downward  into  the  vagina.  If  it 
is  impossible  at  first  to  reach  above  the  retained  ovum,  what  is 
within  reach  may  be  removed  first.  Then  the  uterus  contracts  up, 
as  it  is  emptied,  with  the  aid  of  external  pressure,  and  brings  the 
remainder  within  reach.     The  finger  should  not  be  finally  withdrawn 


Premature  Expulsion  of  the  Ovum.        583 

until  the  cavity  is  to  a  great  extent  closed  up,  otherwise  bleeding 
may  occur,  and  clots  be  formed  within  it.  In  closing  up,  the  cavity 
tends  to  resume  the  flattened  form  it  has  in  the  unimpregnated 
uterus.  The  right  index  finger,  sweeping  across  from  the  left  to 
the  right  cornu,  can  then  finally  make  sure  that  nothing  remains 
attached  to  its  walls. 

When  the  uterus  has  once  fully  retracted  there  is  hardly  ever  any 


Fig.  30.S. — Evacuation  of  the  uterus  in  a  case  of  early  abortion. 


hgemorrhage  beyond  the  ordinary  discharge,  analogous  to  the 
lochial  discharge.  It  hardly  ever  happens,  therefore,  that  any 
styptic  is  required  to  arrest  bleeding.  If  contraction  fails  and 
serious  bleeding  does  occur,  an  intra-uterine  douche  of  sterile 
water,  lysol  solution  1  per  cent.,  or  any  other  weak  antiseptic 
lotion  at  a  temperature  of  115'^  to  118°  F.,  should  be  employed,  or 
if  this  fails  to  arrest  the  bleeding  the  uterus  should  be  plugged  with 
antiseptic  gauze  as  tightly  as  possible.     In  the  case  of  an  early 


584 


The  Practice  of  Midwifery. 


abortion   this   is  an  easy   and   certain   method   of   arresting   the 
bleeding. 

There  are  two  causes  which  are  apt  to  render  it  difficult  to  get 
the  uterus  into  the  requisite  position  of  anteflexion — first,  rigidity 
of  the  abdominal  muscles,  or  thickness  of  abdominal  walls  ;  and, 
secondly,  a  niore  or  less  retroverted  or  retroflexed  position  of  the 
uterus.  The  difficulty  is  greatest  when  the  two  are  combined,  for 
then  the  external  hand  cannot  get  behind  the  fundus  without  being 
pressed  in  very  deeply,  and  this  the  abdominal  walls  will  not  allow. 
Several  expedients  may  be  used  to  overcome  the  difficulty.  Kigidity 
of  muscles  is  most  completely  overcome  by  an  anaesthetic,  and  in 
all  cases  it  is  better  to  administer  one.  When 
the  muscles  are  once  fully  relaxed  by  this 
means,  there  is  rarely  any  difficulty. 

There  are  other  means,  however,  which 
often  suffice,  without  the  use  of  an  anaesthetic. 
If  the  woman  has  had  children  previously, 
it  will  frequently  be  possible  to  pass  the  half- 
hand  (excluding  the  thumb)  or  even  the  whole 
hand  into  the  vagina.  The  index  finger  can 
then  be  passed  into  the  cervix,  and  used  like 
a  rej)ositor,  as  in  restoration  of  the  uterus  by 
the  sound,  so  as  to  bring  the  uterus  forward 
into  anteversion,  and  enable  the  external  hand 
to  command  the  fundus.  If  the  half-hand 
cannot  be  passed  into  the  vagina,  it  may  be 
possible,  by  the  use  of  a  vulsellum,  such  as 
that  shown  in  Fig.  304,  to  get  the  index  finger 
far  enough  into  the  cervix  to  act  as  a  repositor. 
The  tenaculum  is  fixed  firmly  into  the  anterior 
lip,  and  the  cervix  is  drawn  forward  while  the  finger  is  passed  into  it. 
The  tenaculum  may  then  be  given  to  an  assistant,  to  keep  up  the 
traction,  while  the  left  hand  is  transferred  to  the  abdomen,  and  the 
uterus  brought  into  the  position  already  described.  It  is  better  to 
make  counter-pressure  with  the  external  hand,  rather  than  counter- 
traction  with  the  tenaculum,  during  the  evacuation  and  passage  of 
the  finger  up  to  the  fundus,  otherwise  the  cervix  may  possibly  be 
lacerated  by  the  tenaculum.  When  an  offensive  discharge  is 
present,  it  is  better,  if  possible,  to  avoid  the  use  of  the  tenaculum, 
for  fear  that  the  punctures  might  afford  a  site  for  septic 
absorption. 

Various  ovum  forceps  have  been  devised  to  remove   ovum   or 
placenta,  but  the  finger  is  a  far  better  instrument  than  any.     If  the 


Fig.  30i.— Author's 
uterine  vulsellum. 


Premature  Expulsion  of  the  Ovum.        585 


placenta  is  adherent,  it  has  generally  to  be  removed  in  pieces. 
Even  though  adherent  or  indurated,  placental  tissue  is  always  soft 
enough  to  be  gradually  broken  up  and  detached  from  the  uterine 
wall  by  the  pulp  of  the  finger  without  use  of  the  nail.  As  any  piece 
is  detached,  it  is  hooked  between  the  finger  and  the  uterine  wall, 
and  drawn  out  of  the  uterus.  The  finger  is  then  again  introduced, 
and  so  on  till  the  whole  is  removed.  As  the  uterus  is  emptied,  it 
generally  contracts  up  upon  the  finger,  diminishing 
its  cavity,  and  so  facilitating  the  evacuation.  The 
operator  should  never  desist  until  he  has  com- 
pletely reached  the  fundus  with  his  finger,  and 
made  sure  that  all  placenta  is  removed,  leaving 
nothing  more  than  roughness,  or  slight  shreds,  at 
the  placental  site.  For  if  some  of  the  placenta  is 
left,  after  entry  of  air  has  been  facilitated  by  inser- 
tion of  the  finger,  there  may  be  more  decomposition, 
and  worse  results  than  if  no  interference  at  all  had 
been  undertaken. 

The  only  use  to  which  ovum  forceps  should  ever 
be  applied  is  to  draw  out  of  the  uterus  pieces  which 
have  already  been  detached  or  nearly  detached,  if 
this  cannot  be  done  easily  by  the  finger  alone. 
The  cervix  may  have  contracted  up,  so  as  barely 
to  allow  the  finger  to  pass,  while  the  body  of  the 
uterus  remains  comparatively  large  and  globular. 
It  is  then  difficult  to  hook  a  loose  piece  out  of  the 
wider  cavity  into  the  cervix  already  filled  by  the 
finger.  The  piece  may  then  be  grasped  by  forceps, 
guided  up  to  it  by  the  finger.  Forceps  for  this 
purpose  should  be  somewhat  curved  to  suit  the 
genital  canal :  the  blades  should  be  not  more  than 
half  an  inch  wide,  and  should  have  transverse 
ridges,  interlocking  with  each  other,  so  as  to  give 
a  firm  grasp  (see  Fig.  305). 


Fig.  305.— Ovum 
forceps. 


Treatment  of  Incomplete  Abortion.  —  If  the  foetus  has 
escaped  and  the  placenta  or  decidua  remains  behind,  it  is  of 
the  greatest  importance  to  effect  an  early  and  complete  evacuation 
of  the  uterus.  Though  this  principle  is  generally  accepted  by  all 
good  authorities,  it  is  not  yet  universally  carried  out  in  practice. 
Digital  extraction  of  the  placenta  is  necessarily  unpleasant  to  the 
patient ;  and,  if  she  is  intolerant  of  manipulation,  and  reluctant  to 
take  an  anajsthetic,  there  is  a  temptation  to  leave  the  case  to  nature — 


586  The  Practice  of  Midwifery. 

at  any  rate,  until  decomposition  occurs,  or  constitutional  disturbance 
arises.  It  is  true  that  the  patient  generally  recovers,  if  this  practice 
be  adopted,  and  that  the  placenta  is  usually  expelled  after  a  few  days. 
The  disadvantages,  however,  are  many.  There  is  some  risk  of  even 
fatal  septicaemia.  The  jolacenta,  if  adherent,  is  generally  not 
expelled  till  softening  by  decomposition  has  begun,  and  fragments 
of  it  are  apt  even  then  to  be  retained,  and  to  cause  persistent  or 
recurrent  haemorrhage.  The  patient  generally  goes  through  a  stage 
of  febrile  disturbance,  due  to  some  degree  of  septic  absorption,  and 
often  accompanied  by  some  metritis,  pelvic  peritonitis,  or  cellulitis. 
As  a  result  of  this,  the  natural  involution  of  the  uterus  is  retarded 
by  the  active  hyperaemia  kept  up  by  the  inflammation,  and  chronic 
uterine  trouble  is  apt  to  remain  afterwards. 

Immediate  emptying  of  the  uterus  must  be  the  invariable  rule  in 
all  cases  where  the  haemorrhage  is  excessive,  the  temperature  at  all 
raised,  or  the  discharge  in  the  least  degree  offensive.  If  none  of 
these  indications  are  present,  the  length  of  time  for  which  the 
placenta  may  be  left  must  depend  upon  the  circumstances  of  the 
case.  If  the  patient  is  tolerant,  and  the  uterus  can  be  easily  cleared 
out  without  an  anaesthetic,  it  is  well  not  to  wait  more  than  an  hour 
after  the  passage  of  the  foetus.  The  cervix  is  then  sure  to  be  large 
enough  to  let  the  finger  pass  easily,  whereas  later  on  it  may  have 
closed  up  again  more  or  less.  If  an  anaesthetic  is  required,  there 
should  be  an  assistant  to  administer  it ;  for  the  operation  must  be 
carried  out  verj'  deliberately  and  carefully,  and  an  imperfect 
evacuation  is  often  worse  than  no  interference  at  all.  Meanwhile 
the  placenta  should  not  be  allowed  to  remain  more  than  about 
twelve,  or,  at  the  outside,  twenty-four  hours.  If  the  assistance  of 
an  expert  in  obstetrics  is  available  for  the  operation,  it  is  often  of 
advantage.  If  there  is  haemorrhage,  the  vagina  may  be  plugged 
meanwhile,  care  being  taken  either  to  use  iodoform  gauze  or  to 
moisten  the  strips  of  sterilised  lint  with  some  antiseptic — lysol, 
•5  per  cent.  ;  perchloride  of  mercury,  1  in  3,000;  or  cyllin,  '5  per 
cent. — and  not  to  leave  the  plug  more  than  twelve  hours  at  the 
utmost.  On  removal  the  placenta  will  sometimes  be  found  lying 
above  the  plug.  The  less  the  haemorrhage,  the  greater  is  the  pro- 
bability that  the  j)lacenta  is  firmly  adherent,  and  not  likely  to  be 
expelled  by  nature.  The  operation  is  to  be  carried  out  according 
to  the  method  already  described. 

It  may  happen  that  the  case  is  only  seen  at  a  later  stage,  when 
the  placenta  has  been  already  retained  for  days,  or  when  doubt 
exists  whether  it  has  come  away  or  not.  Or  again,  haemorrhage 
may  be  persisting  or  recurrent  at  a  considerable  interval,  even  for 


Premature  Expulsion  of  the  Ovum.        587 


weeks,  after  the  commencement  of  the  abortion.  The  presence  of 
an  offensive  discharge,  or  the  large  size  of  the  body  of  the  uterus 
felt  bimanually,  will  be  a  sign  that  the  uterus  is  certainly  not 
emptied.  In  any  case  the  principle  of  treatment  is  the  same  as  in 
the  former  instance,  namely,  to  exj)lore  completely  the  uterine 
cavity  up  to  the  fundus,  and  make  sure  that  it  is  entirely  emptied. 
The  course  of  action  to  be  adopted 
will  depend  upon  the  condition  of 
the  cervix.  If  any  considerable 
portion  of  the  placenta  remains, 
especially  when  there  is  enough  to 
cause  an  offensive  discharge,  the 
cervix  will  generally  remain  open 
enough  to  allow  the  finger  to  be 
passed  through  with  steady  pres- 
sure, an  anaesthetic  being  given  if 
required.  If  the  cervix  has  closed 
up  too  much  for  this,  as  is  often 
the  case  if  only  minute  fragments  of 
placenta  remain,  or  if  the  haemor- 
rhage is  due  not  to  retained  pla- 
centa, but  to  a  granular  or  villous 
condition  of  the  uterine  mucous 
membrane  remaining  after  the  abor- 
tion, it  must  first  be  dilated.  This 
is  a  case  in  which  rapid  dilatation 
with  Hegar's  dilators  should  be 
carried  out. 

If  any  adherent  placenta  is  found, 
the  finger  will  generally  suffice  to 
detach  it.  If  not,  a  curette  may 
be  used  for  the  purpose.  If  there 
is  evidence  of  sepsis,  or  decomposed 
material  is  present,  the  blunt  irri- 
gating curette  (Fig.  306)  may  be 
employed,  so  that  all  debris  detached 

is  at  once  washed  away  by  an  antiseptic  solution.  Lysol  1  per 
cent.,  tinct.  iodi  5j.  ad  Oj.,  or  iodide  of  mercury  1  in  4,000,  in  boiled 
water,  may  be  used  for  the  purpose.  If  no  placenta  is  found,  but 
only  a  roughened,  softened,  or  villous  condition  of  mucous  mem- 
brane as  a  source  of  hgemorrhage,  the  surface  should  be  scraped 
with  the  sharp  steel  curette  (Fig.  307),  and  iodised  phenol  applied 
afterwards  on  a  sound  or  Playfair's  probe  wrapped  in  absorbent 


Fig.  306.— Iirl^ 
ing  curette. 


Fig.  307.— Sim's 
curette  with 
metal  liandle. 


588  The  Practice  of  Midwifery. 

cotton  wool.  The  curette  will  also  remove  any  small  fragments  of 
ovum  or  decidua  which  may  remain  adherent.  Some  authorities 
advise  plugging  the  uterine  cavity  with  iodoform  gauze  after 
curetting.  In  the  absence  of  sepsis  this  is  unnecessary,  but  it  is 
advisable  if  there  is  evidence  of  septic  endometritis.  Sterilised 
moist  iodoform  gauze,  10  per  cent.,  is  the  best  for  the  purpose.  If 
plugging  is  employed,  no  caustic  should  be  used  to  the  endometrium. 

If  severe  febrile  symjDtoms  arise  within  a  few  days  after  an 
abortion,  and  there  is  not  evidence  that  the  uterus  has  been  com- 
pletely emptied,  it  may  be  presumed  that  there  is  septic  absorption 
from  some  portion  of  ovum  retained  in  the  uterine  cavity.  There 
will  sometimes  be  an  offensive  discharge  to  indicate  this,  but  not 
always.  There  may  be  decomposing  matter  in  the  uteras,  and  no 
indication  of  it  in  the  vagina,  especially  if  vaginal  syringing  has 
been  employed.  The  uterus  should  be  explored  and  emptied  as 
early  as  possible  after  the  outset  of  the  septic  symptoms.  If  the 
patient  is  seen  only  at  a  late  stage,  if  there  is  a  local  swelling  of 
pelvic  cellulitis  or  peritonitis  to  account  for  the  febrile  attack,  if 
the  cervix  has  closed  up  and  uterine  discharge  ceased,  and  it  is 
thought  that  the  decomj^osing  material  has  come  away,  it  may  be 
desirable  not  to  interfere  actively.  In  case  of  doubt,  the  curette 
may  be  used  for  diagnosis,  to  decide  whether  any  pieces  of  ovum 
still  remain. 

If  the  contents  of  the  uterus  have  been  found  offensive,  the 
interior  should  be  washed  out  with  an  antiseptic.  A  solution  of  lysol, 
1  per  cent.,  or  of  iodine,  1 — 2  drachms  to  the  pint,  may  be  used.  The 
best  j)lan  is  to  employ  an  ordinary  douche  with  a  long  rubber  tube 
attached  to  one  or  other  form  of  metal  or  glass  intra-uterine  tube, 
of  which  Budin's  is  one  of  the  best.  Care  must  be  taken  to  avoid 
the  entrance  of  air  by  allowing  the  solution  to  flow  through  the  tube 
and  cannula  before  and  while  it  is  being  introduced  into  the 
uterus. 

The  so-called  placental  or  fibrinous  polypus  (see  p.  575)  may 
offer  some  obstacle  to  detachment  by  the  finger,  if  the  pedicle  is 
small,  on  account  of  its  slippery  character.  In  such  a  case  it  may 
be  removed  with  a  pair  of  ovum  forceps  and  the  remains  of  the 
pedicle  detached  with  a  curette. 

Treatment  of  Abortion  in  the  later  months.^ — In  the  fifth  and 
sixth  months  interference  for  arrest  of  haemorrhage  is  much 
more  rarely  required  before  the  birth  of  the  foetus.  After  delivery, 
contraction  of  the  uterus  must  be  secured,  as  in  labour  at  term,  by 


Premature  Expulsion  of  the  Ovum.        589 

external  pressure,  as  a  safeguard  against  haemorrhage.  An  attempt 
may  be  made  to  effect  the  expulsion  of  the  placenta  by  the  method 
of  expression  (see  p.  309).  Failing  this,  it  will  generally  be  neces- 
sary for  its  removal  to  introduce  the  half  or  whole  hand  into  the 
vagina,  and  two  fingers  or  the  half-hand  into  the  uterus.  If  the 
placenta  is  attached  on  the  right  side  of  the  uterus,  it  is  most  easy 
to  detach  it  by  introducing  the  right  hand,  a.nd  conversely,  so  that 
the  tips  of  the  fingers  may  detach  the  upper  border  of  the  placenta 
first. 

After-treatment. — Patients  are  commonly  inclined  to  make  too 
light  of  an  abortion,  and  to  get  about  too  soon.  This  it  one  of  the 
reasons  why  chronic  uterine  disease  is  so  often  a  sequel.  As  a  rule 
confinement  to  bed  as  long  as  after  labour  at  term,  or  at  any  rate 
until  all  sanguineous  discharge  has  ceased,  is  desirable.  After  a 
severe  abortion  in  the  third  or  fourth  month  with  difficult  extrac- 
tion of  the  placenta,  still  more  prolonged  rest  is  often  called  for. 
Care  should  be  maintained  for  some  weeks  more,  with  a  view  to 
preventing  the  subinvolution  of  the  uterus  which  is  apt  to  remain. 
Involution  may  be  assisted  by  a  course  for  some  weeks  of  the  liquid 
extract  of  ergot  in  half-drachm  doses,  or  two  or  three  grains  of 
ergotin  in  pill  three  times  a  day.  A  grain  or  two  of  sulphate  of 
quinine  may  often  be  added  with  advantage,  or  iron  if  there  is 
anaemia  after  haemorrhage. 


Chaptef  XXV. 

HEMORRHAGE  IN  PREGNANCY. 

The  consideration  of  hfemorrhage  in  the  earlier  months  of 
pregnancy  resolves  itself  almost  entirely  into  the  consideration  of 
threatened  abortion,  Avhich  has  already  been  discussed.  For  the 
causes  tending  to  h?emoirhage  tend  also  to  excite  premature 
expulsion  of  the  ovum ;  and  the  haemorrhage  itself,  by  separating 
the  placenta,  or  leading  to  the  formation  of  clots  which  irritate  the 
uterus,  increases  this  tendency.  Placenta  previa,  so  important  a 
cause  of  haemorrhage  toward  the  end  of  pregnancy,  may  also  be  a 
cause  of  it  in  the  months  which  follow  the  differentiation  of  the 
placenta.  No  doubt  even  before  this,  an  incorrect  implantation 
of  the  ovum  may  have  the  same  effect,  though  such  a  cause  will 
generally  escape  recognition.  Placenta  praevia  is,  however,  only 
the  cause  of  a  relatively  small  proportion  of  the  cases  of  haemorrhage 
occurring  in  the  early  and  middle  months.  In  persistent  or  re- 
current haemorrhage  in  the  fourth  or  fifth  month,  without  obvious 
exciting  cause  of  abortion,  placenta  praevia  is  not  found  in  more 
than  one-fifth  of  the  cases.  Some  authorities,  however,  hold  that 
a  development  of  part  of  the  placenta  on  the  decidua  reflexa  is  a 
more  frequent  source  of  haemorrhage  and  abortion  in  the  early 
months  than  has  generally  been  supposed. 

Menstruation  in  Pregnancy. — That  the  menstrual  nisus  does 
to  a  certain  degree  persist  during  pregnancy  is  shown  by  the 
special  liability  to  abortion  at  what  would  have  been  menstrual 
periods,  as  well  as  by  the  presumed  onset  of  labour  at  the  tenth 
epoch  after  the  last  menstruation.  Ovulation,  however,  during 
pregnancy  is  an  occurrence  of  extreme  rarity.  It  is  probable 
that  in  many  cases  in  which  women  themselves  give  a  history 
of  menstruation  in  pregnancy,  the  bleeding  has  not  been  suffi- 
ciently regular  in  its  occurrence  to  entitle  it  to  this  description, 
but  has  been  really  a  bleeding  indicating  a  threatened  abortion. 
Menstruation  in  pregnancy  is  occasionally  met  with,  but  is 
extremely  rare,  so  that,  in  any  case  of  doubtful  pregnancy,  the 
persistence  of  menstruation,  however  scanty,  is  a  strong  pre- 
sumption against  the  pregnancy  existing.     The  occurrence  of  one 


Haemorrhage  in  Pregnancy.  591 

menstruation,  or  apparent  menstruation,  after  conception,  is  not, 
however,  so  very  uncommon.  It  is  much  more  rare  for  it  to  be 
repeated  two,  three,  four,  or  five  times,  and  still  far  more  so  for  it 
to  continue  up  to,  or  nearly  up  to,  full  term. 

Up  to  the  fourth  month  there  is  a  decidual  cavity,  between  the 
decidua  vera  and  refiexa,  and  it  is  therefore  possible  for  menstrua- 
tion to  take  place  from  the  surface  of  the  mucous  membrane.  It 
is  not  positively  known  whether  in  the  menstruation  of  pregnancy 
any  exfoliation  of  the  surface  takes  place,  as  in  ordinary  menstrua- 
tion, but  this  can  hardly  occur  to  any  extent  without  involving  also 
the  separation  of  the  decidua  basalis. 

Women  who  menstruate  in  j^regnancy  rarely  have  a  perfectly 
healthy  uterus.  Sometimes  they  have  suffered  previously  from 
menorrhagia.  Frequently  they  are  multiparse,  and  have  erosion 
or  granular  inflammation  of  the  cervix  from  the  effect  of  previous 
parturition.  It  is  believed  that,  in  many  cases,  this  inflamed  cervix 
is  the  site  of  the  bleeding.  If  the  blood  comes  from  the  body  of  the 
uterus,  probably  exfoliation  or  rupture  of  superficial  vessels  is  only 
slight.  After  the  fourth  month,  if  menstruation  continues,  either 
the  blood  must  come  from  the  cervix,  or  there  must  be,  in  fact,  a 
threatening  of  abortion  at  each  month.  A  double  uterus  has  not 
been  found  to  exist  in  recorded  cases  of  menstruation  in  the  later 
months,  and  would  not  account  for  the  occurrence  if  it  did  exist, 
for  the  decidua  formed  in  the  unimpregnated  side  is  generally 
retained  until  after  parturition.  Menstruation  in  pregnancy  must 
therefore  be  regarded  as  a  morbid  occurrence,  and  women  who  so 
menstruate  should  take  special  care  to  rest  at  the  periods,  as  being 
liable  to  the  risk  of  abortion. 

HAEMORRHAGE     IN     THE     LATER      MoNTHS      OF      FreGNANCY,     PlACENTA 

Previa,  Accidental  HiBMORRHAGB. 

It  has  been  usual  to  divide  haemorrhage  in  the  later  months  of 
pregnancy,  and  before  parturition,  into  two  classes,  "  unavoidable 
haemorrhage,"  that  is,  hsemorrhage  due  to  placenta  prsevia,  or 
implantation  of  the  placenta  so  low  down  in  the  uterus  that  it  must 
become  detached  in  the  dilatation  of  the  cervix,  and  "  accidental 
bajmorrhage,"  or  hsemorrhage  due  to  partial  separation  of  a 
normally  situated  placenta. 

Placenta  Pr;rvia. 

Definition. — In  placenta  praevia,  the  placenta,  instead  of  being 
attached  near  the  fundus,  is  situated  low  down  in  the  body  of  the 


592 


The  Practice  of  Midwifery. 


uterus,  and  is  found  in  the  later  months  either  approximating  to 
or  overlapping  the  internal  os,  so  that  a  part  of  its  insertion  is  on 
the  lower  segment  of  the  uterine  body  which  has  to  be  stretched 
to  allow  the  fcetus  to  pass.  In  Fig.  308,  it  is  evident  that 
dilatation  of  the  os  to  the  size  indicated  by  the  dotted  lines  inevitably 
detaches  the  lower  part  of  the  placenta,  whether  it  stops  just  short 
of  the  internal  os  or  overlaps  it.  When  it  was  believed,  as  formerly, 
that  a  large  part  of  the  cavity  of  the  cervix  was  taken  up  into  the 


Fig.  308. — Placenta  piaevia.  Two  varieties  of  insertion  are  indicated  :  one  in 
which  the  placenta  overlaps  considerably  the  internal  os,  and  would 
appear  as  a  complete  placenta  prsevia  when  the  os  was  partially  dilated  ; 
one  in  which  it  is  attached  just  short  of  the  internal  os,  and  would  appear 
as  partial  placenta  preevia,  when  the  os  was  partially  dilated. 


cavity  of  the  body  of  the  uterus  with  the  advance  of  pregnancy,  it 
was  thought  that  the  placenta  might  be  attached  to  the  internal 
surface  of  the  cervix.  The  phrase  which  has  more  recently  been 
used  of  attachment  of  the  placenta  to  the  "  cervical  zone  "  of  the 
uterus  has  also  led  sometimes  to  misconception.  It  must  be  clearly 
borne  in  mind,  therefore,  that  only  the  body  of  the  uterus  can  give 
attachment  to  the  ovum,  and  that  the  mucous  membrane  of  the 
cervix  is  not  adapted  to  this  purpose.  Although  the  theory  of  the 
expansion  of  the  upper  part  of  the  cervix  has  again  been  revived  of 
late  (see  p.  158),  there  is  no  doubt  that,  in  placenta  prsevia  covering 


Haemorrhage  in  Pregnancy. 


593 


the  internal  os  uteri  (see  Fig.  308,  p.  592)  at  any  rate,  the  internal 
OS  remains  undilated  up  to  the  time  that  haemorrhage  first  occurs. 

Causation. — The  position  of  the  placenta,  when  it  is  found  to 
be  prsevia  in  the  later  months  of  pregnancy,  may  result  either 
from  the  ovum  having  been  originally  attached  in  the  lower 
segment  of  the  body  of  the  uterus,  or  from  part  of  the  placenta 
having  been  developed  upon  the  decidua  reflexa  on  the  lower  side 
of  the  ovum,  or  from  both  these  conditions  combined.  Both  have 
been  demonstrated  as  existing  in  the  earlier  months  of  pregnancy. 

Now  that  it  is  known  that  the  ovum  burrows  at  once  into  the 


Placenta 


Internal  os 


Keflexal 
placenta 

Decidual 
cavity 


Bladder 


Fig.  309. — Diagram  of  reflexal  development  of  placenta  at  three  months' 
pregnancy,  which  vs^onld  lead  to  placenta  praevia  overlapping  the  internal 
OS  in  the  later  months. 

mucous  membrane  on  its  attachment,  it  is  evident  that  a  placenta 
covering  the  internal  os  before  dilatation  can  only  be  due  to  a 
reflexal  development  of  placenta,  since  the  ovum  must  have  been 
originally  on  one  side  or  other  of  the  os.  It  is  probable  that 
both  causes  act  together  in  producing  a  complete  placenta  prsevia. 
For,  if  the  ovum  is  attached  near  to  the  internal  os,  the  expansion 
of  the  decidua  basalis  will  be  impossible  in  the  direction  of  the 
cervical  canal,  and  the  necessary  placental  space  may  in  conse- 
quence be  obtained  by  its  development  on  the  decidua  reflexa,^ 
which  eventually  becomes  adherent  to  the  uterine  wall  so  as  to 
overlap  the  internal  os.  In  such  a  case  the  reflexal  portion  of  the 
placenta   is   but   imperfectly   attached   to   the   decidua  vera,    and 

1  Hofmeier,  Verhandlungea  der  Dcutschen  Gcsellsch.,  18'J7,  p.  204. 
M.  38 


594  The  Practice  of  Midwifery. 

therefore  the  separation  of  the  two  can  occur  without  much 
haemorrhage  taking  place. 

Placenta  prgevia  is  comparatively  rare  in  primiparse  and  relatively 
common  in  women  who  have  had  a  number  of  children,  especially 
if  the  pregnancies  have  followed  in  rapid  succession.  It  may  be 
inferred  that  it  depends  upon  some  morbid  condition  of  the  uterus 
previous  to  conception,  and  this  conclusion  is  often  confirmed  by  the 
previous  history  of  patients  in  whom  this  condition  is  found.  It  is 
probable  that  the  chief  element  in  causation  is  a  dilatation  of  the 
cavity  of  the  uterus,  due  to  subinvolution,  hypertrophy,  or 
endometritis.  The  effect  of  this  is  likely  to  be  that  the  ovum, 
instead  of  being  arrested  at  once  by  the  mucous  membrane  nearly 
filling  up  the  cavity  when  it  reaches  the  uterus  from  the  Fallopian 
tube,  is  liable  to  fall  down  to  a  lower  part  of  the  uterus  before  it 
becomes  attached.  It  is  possible  also  that  an  inflammatory  condi- 
tion of  the  mucous  membrane  rendering  the  implantation  of  the 
ovum  less  easy,  or  atrophy  leading  to  imperfect  vascularisation  and 
nutrition  of  the  decidua,  may  have  some  influence  in  the  matter. 

Some  authorities  have  ascribed  j)lacenta  praevia  entirely  to 
reflexal  development  of  the  placenta.  The  possibility  of  a  very  low 
attachment  to  the  ovum,  however,  is  demonstrated  by  a  case, 
figured  by  Hunter,^  of  an  abortion  of  four  weeks,  in  which  there  is 
a  complete  decidual  cast  of  the  uterus,  with  an  ovum  implanted  at 
its  lowest  extremity. 

The  difficulty  of  explaining  the  central  attachment  of  the  ovum 
over  the  internal  os  has  been  overcome  by  the  suggestion  that  the 
developing  ovum  when  it  reaches  the  uterus  is  larger  than  the 
opening  of  the  internal  os,  and  that  very  speedily  after  implantation 
in  that  situation  the  two  walls  of  the  canal  coalesce,  and  further 
embedding  of  the  ovum  takes  place  in  relation  to  both. 

A  placenta  praevia  is  often  found  thinner  and  more  widespread 
than  usual.  The  explanation  may  be  either  that  a  more  extended 
placenta  has  a  greater  chance  of  overlapping  the  zone  of  detach- 
ment, or  that  the  reflexal  portion  of  the  placenta,  to  which  there  is 
less  free  access  of  blood,  has  to  be  more  widespread  to  compensate 
for  this  defect.  The  latter  j)rinciple  holds  true  to  some  extent  at 
any  rate,  for  there  is  generally  a  special  thinness  around  the 
position  of  the  internal  os,  and  in  that  part  of  the  placenta  which  is 
on  the  opposite  side  of  the  internal  os  to  the  main  mass. 

Another  explanation  has  been  put  forward  by  Strassmann^  who 

1  Anat.  Uteri  Humani  Grav.,  1851,  PI.  XXXIV.,  Figs.  1  and  2. 

2  Strassmann,  Zeitschr.  f.  Geb.  u.  Gyn.,  1901.  Bd.  41,  s.  529  ;  Archiv  f.  Gynak., 
1902,  Bd.  67,  Hft.  1,  s.  112. 


Haemorrhage  in  Pregnancy. 


595 


considers  it  is  due  to  a  deficient  vascularisation  of  the  decidua,  the 
sequel  of  old  chronic  endometritis. 

The  facts  now  known  with  regard  to  the  embedding  of  the  early- 
ovum  and  the  splitting  of  the  decidua  vera  to  form  the  decidua 
capsularis  offer  another  and  very  probable  explanation  of  the 
development  of  at  any  rate  some  cases  of  placenta  prsevia.  If,  for 
example,  with  a  rather  low  or  "  vicious  insertion  "  of  the  placenta, 
as  it  has  been  called,  such  splitting  of  the  decidua  takes  place  to  an 


Fig.  310. — Central  placenta  prasvia. 


Fig.  311. — Marginal  placenta  prsevia  and 
a  low  implantation  of  the  placenta  in 
lower  uterine  segment. 


excessive  degree,  the  decidua  basalis  may  well  have  an  extended 
attachment  to  the  lower  uterine  segment  and  so  lead  to  the 
formation  of  a  placenta  prsevia.  It  is  probable  indeed  that  a 
primary  low  implantation  of  the  ovum  with  an  excessive  splitting 
of  the  decidua  is  the  real  explanation  of  the  majority  of  these 
cases. 


Varieties. — It  has  been  usual  to  divide  placenta   prsevia  into 
three  varieties,  complete,  or  central,  when  the  whole  of  the  os  is 

38—2 


596 


The  Practice  of  Midwifery. 


covered  by  placenta  j^a-i'tial,  the  commonest  variety,  when  it  is  only 
partially  covered  ;  and  marginal,  when  the  placenta  just  reaches 
the  edge  6t  the  os.  The  true  view  ^of  the  relation  of  placenta 
preevia  to  the  internal  os  being  adopted,  these  varieties  have  no 
longer  any  strict  accuracy.  The  varieties  are  still  retained,  but 
are  judged  of  according  to  the  relation  of  the  placenta  to  the 
internal  os  when  an  examination  is  made,  partial  dilatation  of  the 


Fig.  312. — Placenta  previa,  undisturbed  by  any  commencement  of  labour. 
The  placenta  just  covers  the  internal  os  ;  the  cervical  canal  is  intact. 
(After  Ahlfeld.) 


OS  having  taken  place.  The  classification  of  any  given  case  may 
therefore  vary  according  to  the  stage  of  dilatation  reached.  Many 
cases  in  which  the  placenta  overlapped  the  undilated  os  will  appear 
as  cases  of  only  partial  placenta  praevia  at  the  later  stage  ;  and 
many  again  in  which  it  only  approached  the  os  and  did  not  overlap 
it  at  all  will  likewise  appear,  at  the  same  stage,  as  cases  of  partial 
j)lacenta  prgevia,  only  somewhat  less  in  degree.  Further,  the  edge 
of  the  placenta  may  reach  withm  the  zone  of  necessary  detachment 
and  yet  never  overlap  the  internal  os  at  all,  even  when  dilated.   In 


Haemorrhage  in  Pregnancy.  597 

such  cases  the  placenta  would  be  detected  only  if  the  finger  were 
passed  within  the  uterus.  It  is  only  when  the  placenta  approxi- 
mates more  or  less  toward  a  central  position  that  it  continues  to 
appear  as  a  complete  placenta  prsevia  throughout  the  whole 
dilatation  stage. 

A  more  exact  classification  may  be  made  of  placenta  prsevia  as  it 
exists  before  any  dilatation  of  the  internal  os  has  begun.  There 
are  then  only  two  varieties,  one  in  which  the  placenta  only 
approximates  to  the  internal  os,  but  does  not  overlap  it,  and  one 
in  which  it  overlaps  it.  The  first  is  called  marginal  placenta 
prsevia  ;  the  second  must  be  called  complete  placenta  prsevia  ;  even 
if  only  the  edge  of  the  placenta  overlaps  the  os  (Fig.  312). 

Frequency. — The  frequency  of  placenta  prsevia  has  been 
variously  estimated  at  from  1  in  573  (Johnson  and  Sinclair : 
Dublin)  to  1  in  1,564  deliveries  (Schwarz :  Germany).  In  the 
Guy's  Hospital  Lying-in  Charity,  in  49,845  deliveries,  the  propor- 
tion was  1  in  534.  Only  about  4*4  per  cent,  of  the  patients  were 
primiparse. 

Pathological  Anatomy. — The  lower  segment  of  the  uterus  may 
be  regarded  as  nearly  equivalent  to  a  hemisphere  in  shape,  the 
undilated  internal  os  being  at  the  centre  of  the  curved  surface.  In 
its  dilatation  for  the  passage  of  the  child  this  hemisphere  has  to  be 
converted  into  a  cylinder  equal  in  capacity  to  the  circumference  of 
the  hemisphere.  Hence  each  ring  of  the  hemisphere  has  to  be 
stretched,  the  stretching  rapidly  increasing  in  degree  as  the  os  is 
approached.  It  is  therefore  easy  to  understand  that,  when  the 
attachment  of  the  placenta  overlaps  any  ring  of  the  uterus  which 
is  stretched  at  all  considerably,  the  placenta  cannot  follow  the 
stretching  but  becomes  detached,  and  so  causes  inevitable 
haemorrhage  in  the  first  stage  of  labour.  If  the  foetal  head,  as 
presented  to  the  genital  canal,  be  taken  as  about  3^  inches  in 
average  diameter,  and  the  lower  segment  of  the  uterus  therefore 
compared  to  a  hemisphere  having  the  same  diameter,  it  will  be 
found  the  zone  of  the  uterus  liable  to  stretching  extends  about 
2?^  inches  from  the  original  position  of  the  internal  os,  the  distance 
being  measured  from  the  os  along  the  chord,  or  nearly  3  inches, 
if  measured  along  the  arc.  There  is  a  narrow  zone,  at  the  upper 
part  of  this  dilatable  zone,  in  which  the  stretching  is  only  slight, 
and  the  placenta  may  be  able  to  yield  to  it  without  detachment. 
Any  slight  degree,  however,  of  those  causes  liable  to  cause  detach- 
ment of  a  normally  situated  placenta,  such  as  shocks  or  l)lows,  will 


598  The  Practice  of  Midwifery.    - 

be  apt,  during  the  first  stage  of  labour,  to  cause  detachment  and 
bleeding  very  easily,  the  placenta  being  already  on  the  strain. 
Speaking  roughly,  it  may  be  estimated  that  a  zone  reaching  to 
about  2  inches  from  the  undilated  internal  os,  measuring  along 
the  arc,  is  the  zone  of  necessary  detachment,  and  that  above  this 
there  is  another  zone  measuring  about  an  inch  or  a  little  more  in 
width,  which  is  the  zone  of  possible  detachment,  or  dangerous 
insertion.  If  the  placental  attachment  overlaps  the  first  zone, 
hsemorrhage  in  labour  is  unavoidable ;  if  it  overlaps  only  the 
second,  haemorrhage  may  occur  from  slight  causes.  Above  these 
zones  is  the  area  of  safe  attachment,  so  far  as  concerns  the  effect 
of  dilatation.  The  placenta  is  in  fact  detached  by  the  same 
mechanism  which  normally  detaches  the  chorion  from  the 
uterine  wall  near  the  lower  pole  of  the  ovum,  and  allows  the  bag 
of  membranes  to  advance  into  the  cervix  and  begin  the  dilatation 
of  the  internal  os.  Such  tendency  to  advance  of  the  presenting 
pole  of  the  ovum  adds  to  the  effect  of  the  transverse  stretching  of 
the  placental  site  in  causing  detachment  of  the  placenta,  especially 
when  the  placenta  praevia  is  complete. 

Source  of  the  Blood. — The  blood  comes  mainly  from  the  arteries 
and  veins  in  the  uterine  wall  separated  from  the  placenta,  but  to 
some  extent  also  from  the  separated  placental  surface,  especially 
from  the  margin  which,  at  any  moment,  has  just  been  separated. 
It  might  perhaps  have  been  expected  that  the  blood,  constantly 
entering  the  maternal  blood-spaces  which  permeate  the  whole 
placenta,  would  continuously  pour  out  through  the  open  mouths 
of  the  vessels  on  the  separated  surface.  Sir  James  Simpson, 
indeed,  maintained  that  this  was  the  main  source  of  bleeding. 
Any  such  continuous  loss  from  the  placenta  is,  however,  prevented 
by  thrombosis  taking  place  in  the  detached  portion.  Arterial 
bleeding  from  the  uterine  wall  is,  to  a  certain  extent,  kept  in 
check  by  that  very  stretching  of  the  uterine  wall  which  separates 
the  placenta.  A  patient,  therefore,  hardly  ever  bleeds  to  death 
with  the  rapidity  sometimes  seen  in  bleeding  from  the  placental 
site  in  post-jjarUim  haemorrhage. 

Cause  of  Bleeding  before  Fidl  Term. — The  cause  of  the  unavoid- 
able haemorrhage  in  the  first  stage  of  labour  is  obvious  enough,  but 
there  have  been  various  theories  to  account  for  the  haemorrhage 
often  beginning  in  pregnancy,  especially  during  the  last  two  or 
three  months.  When  it  was  believed  that  the  cervix  was  taken 
up  into  the  cavity  of  the  uterus  in  the  course  of  j)regnancy,  such 
expansion  of  the  cervix  from  above  was  believed  to  separate  the 
placenta  ;  but  then  there  was  no  explanation  why  the  haemorrhage 


Haemorrhage  in  Pregnancy.  599 

did  not  always  begin  before  labour.  Barnes  has  supposed  that 
detachment  is  caused  by  excess  of  the  growth  of  the  placenta  over 
that  of  the  corresponding  part  of  the  lower  uterine  segment,  which 
is  not  adapted  for  its  attachment.  Matthews  Duncan  has  supposed 
that  the  causes  are  similar  to  those  of  accidental  haemorrhage, 
only  that  they  act  with  greater  facility  when  the  placenta  is 
prsBvia.  The  real  main  reason  appears  to  be  that,  although  the 
cervix  is  not  usually  taken  up  into  the  cavity  of  the  uterus  long 
before  the  onset  of  labour,  yet  a  slight  temporary  or  permanent 
dilatation  of  the  internal  os  is  very  common  in  the  last  two 
months  of  pregnancy.  It  is  probably  due  to  the  occasional 
uterine  contractions  which  do  not  cause  any  feeling  of  pain  (see 
p.  180).  Thus,  in  multiparse,  it  is  not  uncommon,  in  the  last 
month  or  two,  to  be  able  to  pass  the  finger  through  the  internal 
OS,  and  feel  the  head  presenting.  And  any,  even  the  slightest, 
commencement  of  such  dilatation  of  the  small  internal  os  must 
cause  detachment  of  the  placenta  at  its  edges,  when  it  overlaps 
the  internal  os.  Again,  it  is  probable  that  the  placenta  when 
attached  over  the  internal  os  is  more  liable  to  detachment  from 
coitus  or  other  mechanical  causes  than  when  normally  situated. 
For  shocks  and  jars  are  communicated  more  directly  to  the  cervix 
than  to  the  fundus  of  the  pregnant  uterus,  and  moreover,  in  the 
upright  position  of  the  woman  intra-vascular  pressure  is  greater 
at  the  placenta  when  this  is  praevia.  In  this  case  the  haemorrhage 
would  be  truly  analogous  to  "  accidental  haemorrhage,"  only  pro- 
duced with  greater  facility. 

Besides  its  frequent  thinness  in  the  vicinity  of  the  os,  the 
placenta  often  shows  old  thrombosis  in  the  part  abnormally 
situated,  if  there  has  been  partial  detachment  some  time  before 
labour,  and  consequent  degeneration  of  the  villi.  The  lower 
segment  of  the  uterus  is  thicker  than  usual  in  consequence  of  the 
increased  blood  supply  attracted  to  it  through  the  placental 
attachment.  This  extra  thickness  sometimes  offers  an  impediment 
to  the  easy  dilatation  of  the  cervix.  Thus  some  of  the  most 
remarkable  cases  of  the  so-called  "  trismus "  of  the  uterus,  or 
spasmodic  rigidity  of  the  cervix,  forming  a  grave  obstacle  to  delivery, 
have  been  cases  of  placenta  praevia. 

Presentation  of  Foetus. — In  placenta  praevia  the  frequency  of 
abnormal  presentation  is  very  much  greater  than  the  average. 
According  to  Miiller's  statistics,^  the  proportion  of  vertex  presenta- 
tions is  only  67  per  cent,  instead  of  nearly  97  per  cent.,  the  normal 

'  Placenta  Praevia,  Rtultgait,  1877. 


6oo  The  Practice  of  Midwifery. 

proportion ;  while  pelvic  presentations  form  9"3  per  cent,  (com- 
pared with  the  normal  2*4  per  cent.),  and  shoulder  or  transverse 
presentations,  23  per  cent,  (compared  with  the  normal  0*4  per 
cent.).  This  result  is  partly  due  to  the  frequency  of  premature 
labour,  but  it  appears  to  show  that  placenta  previa  forms  an 
obstacle  to  the  axis  or  the  child  lying  in  the  axis  of  the  uterus.  The 
bulk  of  the  placenta  itself,  which  prevents  the  head  lying  so  low  in 
the  pelvis  in  the  lower  segment  of  the  uterus,  is  probably  the 
principal  cause,  and  it  may  be  that  a  greater  relative  expansion  of 
the  lower  segment  of  the  uterus  has  also  some  influence.  Prolapse 
of  the  funis  is  also  relatively  much  more  frequent  in  placenta 
prsevia,  as  might  be  expected  from  the  greater  vicinity  to  the  os 
uteri  of  its  outer  attachment. 

Symptoms  and  Course. — Although   placenta   prsevia    may  be 
a   cause    of    abortion    in    the    early  months,  yet    cases  positively 
recognised    as    of    this    nature    commonly  cause    symptoms    only 
within  the  last  three  months  of   pregnancy.      The   characteristic 
symptom   is    sudden    and    unexpected    bleeding   from   the  uterus, 
without  adequate    cause.      Sometimes   it  is  induced  by  moderate 
exertion,  such  as  standing  or  walking,  but  it  may  come  on  when 
the  patient  is  in  bed  or  asleep.     The  cases  of  early   haemorrhage 
(seventh   or   eighth  month)   are    generally   those   in    which    the 
placenta  overlaj)s   the   undilated  internal   os.      If   the  margin  of 
the  placenta  reaches,  or  is  in  the  close  vicinity  of  the  os,  bleeding 
may  begin  rather  later  ;  if  the  placental  attachment  only  encroaches 
moderately   upon   the    zone  of  unavoidable  detachment,   bleeding 
generally  only  begins   either  with  the  stage  of  painless  dilatation 
of  the  internal  os  premonitory  of  labour,  or  after  manifest  labour 
pains   have   begun.      The   first  bleeding  may  be  so  violent  as  to 
cause  extreme  ansemia,  and  even   quickly   cause   death.      This  is 
more  apt  to  be  the  case  when  it  occurs  at  or  near  full  term.      The 
bleeding  which  occurs  earlier  in  pregnancy,  unaccompanied  by  any 
pain,  is  generally  not  so  severe  at  first,  and  may  cease  after  a 
short  time.     It  recurs  from  time  to  time,  either  on  slight  exertion 
or  without  any  cause,  and  when  the  first  stage  of  labour  begins 
it  is  apt  to  be  very  copious.     Premature  labour  often  comes  on, 
either    after    the    first,    or,    more    frequently,    with    subsequent 
haemorrhages.     In  other  cases  there  is  no  such  violent  haemorrhage, 
but  continuous  oozing  goes  on  for  days  or  weeks. 

If  left  to  nature,  the  case  may  end  in  death  from  haemorrhage 
before  delivery.  If,  however,  the  uterus  acts  vigorously,  a  natural 
limit  is  put  to  the  bleeding,  especially  when  the  dilated  os  is  only 


Haemorrhage  in  Pregnancy.  60 1 

partially  covered  by  placenta  and  the  membranes  ruptured,  so  that 
there  is  no  obstacle  to  the  rapid  descent  of  the  fcetus.  The  advancing 
head  presses  the  placenta  firmly  against  the  uterine  wall,  and  thus 
forms  a  plug.  If  the  membranes  remain  unruptured,  the  dilating 
lower  uterine  segment  tends  to  become  still  further  separated  from 
the  placenta,  which  cannot  follow  it,  and  severe  bleeding  may  con- 
tinue. The  tendency  to  hgemorrhage  is  less  when  once  the  placenta 
is  separated  so  far  as  separation  is  inevitable,  but  it  may  still  go  on 
from  the  placental  site,  if  the  uterus  is  not  active  enough  to  cause 
pressure  upon  this.  If  the  attachment  is  nearly  central,  the 
placenta  may  be  detached  entirely  by  uterine  action  and  expelled 
before  the  foetus.  The  result  may  be  favourable,  if  the  uterus  is 
acting  strongly ;  and  the  child  even  has  been  born  alive.  In  the 
Guy's  Hospital  Lying-in  Charity,  however,  the  two  cases  of  placenta 
praevia  in  which  this  incident  occurred  were  both  fatal  through 
hsemorrhage. 

Rare  cases  of  placenta  prsevia  are  observed  in  which  hardly  any 
appreciable  haemorrhage  occurs  throughout  the  entire  course. 
These  are  cases  in  which  the  separation  only  begins  with  labour, 
and  in  which  the  uterus  is  active  throughout.  Other  rare  cases 
again  have  been  recorded,  in  which  there  is  absolutely  no  haemor- 
rhage at  the  time  of  labour  itself.  In  these  instances,  the  placenta 
must  have  been  separated  at  an  earlier  period  so  far  as  needful,  and 
thrombosis  have  taken  place  in  the  vessels. 

The  labour  pains  in  placenta  praevia  are  frequently  feeble, 
partly,  in  many  cases,  from  the  labour  being  premature,  partly 
from  the  patient's  exhaustion  through  the  haemorrhage.  As 
already  mentioned,  the  cervix  uteri  sometimes  proves  unusually 
rigid,  notwithstanding  the  tendency  of  the  haemorrhage  to  relax 
it.  Post-partum  haemorrhage  also  is  liable  to  occur,  probably  in 
consequence  of  the  same  condition  of  exhaustion,  and  soon  tells 
seriously  on  the  already  anaemic  patient. 

Diagnosis, — ^In  the  last  three  months,  and  especially  within 
the  last  two  months  of  pregnancy,  placenta  praevia  is  always  the 
most  probable  explanation,  if  sudden  and  considerable  haemorrhage 
comes  on  without  sufficient  exciting  cause,  especially  in  the 
absence  of  pain,  and  the  probability  is  increased  if  similar  attacks 
of  hgemorrhage  are  repeated.  On  vaginal  examination,  if  haemor- 
rhage has  been  only  slight  or  moderate,  the  internal  os  may  not 
be  permeable  to  the  finger.  There  is  then  no  absolutely  certain 
means  of  physical  diagnosis,  but  the  uterus  round  the  cervix  may 
feel   unduly  thick,  and  the  hard  outline  of  the  head  will   not  be 


6o2  The  Practice  of  Midwifery. 

tangible  through  it,  nor  will  ballottement  be  obtainable,  at  any 
rate  where  placenta  is  situated.  There  is  no  certainty  in  any 
auscultatory  signs,  such  as  finding  the  uterine  soufSe  lower  down 
in  the  groins  than  usual.  Vaginal  stethoscopy  has  been  proposed, 
but  could  only  be  of  use  to  those  who  had  practised  it  much  in 
normal  cases.  If  haemorrhage  is  very  considerable,  the  internal 
OS  will  probably  allow  the  finger  to  pass  on  a  little  pressure,  even 
if  not  already  more  dilated.  If  the  os  lies  high  up,  the  half-hand, 
or  if  necessary  the  whole  hand,  should  be  passed  into  the  vagina 
in  order  to  assure  the  diagnosis.  When  the  finger  can  once  be 
passed  through  the  cervix  diagnosis  is  easy.  The  spongy  mass  of 
the  placenta  could  only  be  mistaken  for  clot  or  for  a  hydatidiform 
mole.  Clot  is  easily  removable  by  the  finger,  is  less  firm  and 
spongy,  while  the  placenta  will  be  found  continuous  with  the 
membranes  if  these  can  be  reached.  It  must  be  remembered 
that,  if  only  just  overlapping  the  original  internal  os,  the  edge  of 
the  placenta  is  often  much  thinner  and  more  membranous  than 
usual.  Unless  the  insertion  is  very  nearly  central,  it  will  generally 
not  be  difficult,  passing  the  hand  into  the  vagina,  to  reach  the 
edge  of  the  placenta  in  some  direction,  find  there  the  membranes, 
and  through  them  make  out  what  the  presentation  of  the  foetus 
is.  If  the  membranes  cannot  at  first  be  reached,  the  direction  o£ 
the  nearest  edge  of  the  placenta  will  generally  be  indicated  either 
by  that  part  of  the  placenta  which  is  thinnest,  or  by  that  which  is 
most  separated.     Usually  the  two  indications  coincide. 

Prognosis. — Placenta  prsevia  is  one  of  the  gravest  complica- 
tions of  the  puerperal  state  for  the  mother,  and  the  prognosis  is 
still  graver  for  the  child.  For  the  mother,  besides  the  immediate 
risk  of  haemorrhage,  there  is  that  of  septicaemia  after  labour.  This 
is  due  partly  to  the  increased  tendency  to  absorption  from 
emptiness  of  the  vessels,  partly  to  the  low  position  of  the  placental 
site,  more  exposed  to  the  locbial  discharge  flowing  over  it,  partly 
to  the  manual  interference  and  manipulation  of  the  placental  site 
which  may  have  been  found  necessary,  or  to  retention  of  portions 
of  the  placenta  and  to  the  tearing  of  the  lower  uterine  segment 
or  cervix  which  is  so  likely  to  occur.  For  the  child  the  main 
danger  is  that  of  asphyxia  from  loss  of  maternal  blood  and 
separation  of  a  great  part  of  placenta.  There  is  also  often  that 
of  immaturity,  or  malposition,  or  the  increased  risk  involved 
by  version.  Koblanck  reported  a  mortality  of  3'8  per  cent,  in 
467  cases  in  the  Frauenklinik  in  Berlin.  In  178  cases  treated  by 
bipolar  version  by  eleven  different  operators,   the  mortality  was 


Haemorrhage  in  Pregnancy.  603 

4"5  per  cent. ;  but  in  93  cases  thus  treated  by  three  operators, 
Hofmeier,  Behm,  and  Lomer/  it  was  only  1  per  cent.  The 
mortahty  to  the  children  is  generally  about  60  per  cent.  Kiistner,^ 
however,  who  employs  Champetier  de  Eibes'  bag  extensively, 
reports  a  mortality  of  only  35  per  cent.  It  is  readily  understood 
that  the  result  to  the  mother  depends  largely  upon  the  skilfulness 
of  the  treatment,  and  the  speed  with  which  medical  assistance  is 
obtained.  The  danger  is  greater  the  earlier  the  bleeding  com- 
mences, the  less  it  is  accompanied  by  uterine  action,  the  more 
nearly  central  is  the  placental  insertion,  and  the  greater  the  anaemia 
which  is  brought  about  before  actual  labour. 

Treatment. — A  patient  having  placenta  prsevia  is  never  safe 
until  delivery  is  completed  ;  and  the  chief  danger  is  that  of  violent 
haemorrhage  occurring  in  the  absence  of  medical  assistance.  The 
general  principles  of  treatment  are  to  bring  on  labour  quickly,  to 
shorten  the  process  of  delivery  so  far  as  this  can  be  done  without 
any  forcible  interference,  which  would  incur  the  risk  of  laceration 
or  bruising,  and  meanwhile  to  limit  the  amount  of  haemorrhage  by 
securing  some  form  of  pressure  upon  the  placental  site. 

Induction  of  Labour. — As  a  rule  it  is  desirable  to  induce  labour 
as  soon  as  a  positive  diagnosis  can  be  made.  The  only  exception 
to  this  is  the  case  when  pregnancy  has  not  reached  the  seventh 
month,  when  haemorrhage  is  very  slight,  and  when  medical  assist- 
ance can  be  obtained  at  short  notice.  It  may  then  be  desirable 
to  attempt  to  prolong  the  pregnancy  up  to  seven  months  in  the 
interest  of  the  child,  if  there  is  anxiety  to  save  it.  It  is  to  be 
remembered,  however,  that  the  chance  of  this  is  somewhat  remote 
in  a  case  in  which  haemorrhage  begins  so  early,  since  the  placenta 
then  probably  overlaps  the  internal  os.  If  it  be  decided  to  tempo- 
rise, the  patient  should  be  kept  completely  in  bed,  and  opium  or 
morphia  administered  so  long  as  any  bleeding  occurs.  A  nurse 
may  be  instructed  to  plug  the  vagina  in  case  of  any  sudden 
bleeding. 

If  it  be  decided  to  induce  labour,  the  cervix  not  being  yet 
permeable  to  the  finger,  a  hot  vaginal  douche  may  first  be 
employed,  and  then  one  or  more  tupelo  tents  placed  in  the  cervix, 
and  the  vagina  plugged  beneath  them  in  the  manner  already 
described  (see  p.  581).  In  five  or  six  hours  tents  and  plugs  should 
be  removed,  and  a   vaginal  douche  used   with  lysol   1   per  cent. 

1  "On  Combined  Turning  in  the  Treatment  of  Placenta  Prasvia,"  Amer.  Journ.  of 
Obst.,  1884,  XVn.,  pp.  12:^:^—1260. 

2  "  Ucbcr  Placenta  Pncvia,"  Verb.  d.  Deutschcn  Gcsell.  f.  Gyn.,  1897,  p.  277. 


6o4 


The  Practice  of  Midwifery. 


solution.  If  the  cervix  is  not  yet  permeable  to  two  fingers,  it  will 
probably  be  possible  to  introduce  the  smallest  hydrostatic  dilator, 
and  so  continue  the  dilatation. 

Plugging  the  Vagina  and  Cervix. — If,  at  the  onset  of  haemorrhage, 
the  cervix  is  found  too  small  to  admit  the  finger  to  make  a  positive 
diagnosis,  or  if,  while  allowing  the  placenta  to  be  felt,  it  is  still 
too  small  to  allow  two  fingers  to  pass,  plugging  the  vagina  is  a 
valuable  resource,  and  one  which  can  always  be  carried  out  with 


Fig.  313. — Champetier  de  Kibes'  bag  wi  situ,  in  a  case  of  placenta  prjevia. 

the  materials  at  hand.  It  used  to  be  considered  permissible  in 
placenta  praevia  and  not  in  accidental  haemorrhage,  from  the  idea 
that,  in  the  former  case,  the  plug  actually  compresses  the  bleeding 
site.  It  is  doubtful,  however,  whether  this  is  always  really  the 
case  ;  and  the  most  valuable  effect  is  that  of  stimulating  the  uterus 
by  reflex  action.  The  plugging  is  dangerous  rather  than  useful 
unless  two  points  are  specially  regarded :  first,  that  antisepsis  is 
maintained ;  and,  secondly,  that  the  plugging  is  mechanically 
efficient,  and  really  fills  and  distends  the  vagina.  The  plug  may  be 
either  of  sterilised  iodoform  or  other  antiseptic  gauze,  or  else  of 


Haemorrhage  in  Pregnancy.  605 

plain  gauze  or  cotton  wool  sterilised  by  boiling,  and  soaked  in  a 
somewhat  dilute  antiseptic,  such  as  chinosol  1  in  500  or  lysol  1  in 
100  parts  of  boiled  water.  If  gauze  is  used,  a  rather  thin  strip 
"should  be  taken,  and  with  the  aid  of  a  Sim's  speculum  packed  all 
round  the  cervix,  before  the  os  is  covered.  The  vagina  should  then 
be  filled  to  its  utmost  capacity  down  to  its  outlet ;  and  finally  a 
perineal  pad  placed  over  it,  upon  which  firm  pressure  is  made 
by  a  7"  bandage  fixed  to  a  tight  abdominal  binder.  If  cotton  wool 
is  used,  the  pieces  should  be  taken  one  by  one,  squeezed  free  from 
superfluous  moistare,  and  compressed  into  a  small  compass  before 
insertion.  The  plug  should  not  be  left  more  than  about  twelve 
hours.  For  if  clots  are  allowed  to  remain  and  become  decomposed 
above  the  plug,  symptoms  of  septic  absorption  may  commence 
even  before  delivery,  and  end  in  puerperal  septicaemia  afterwards. 

Use  of  Hydrostatic  Dilators. — If  a  hydrostatic  dilator  can  be 
introduced  into  the  cervix,  it  is  preferable  to  a  vaginal  plug,  for  it 
dilates  the  cervix  more  rapidly,  and  stimulates  uterine  action  more 
powerfully.  It  will  often  be  possible  to  introduce  the  smallest  size 
when  the  cervix  admits  one  finger,  if  the  improved  form  of  Barnes' 
dilator,  described  in  Chapter  XXVII.,  be  used.  The  cervix  will 
then  probably  be  dilated  enough  within  an  hour  to  allow  of  bipolar 
version.  Champetier  de  Eibes'  dilating  bag  (see  Chapter  XXVII.) 
may  also  be  used,  introduced  into  the  amniotic  cavity  after 
rupture  of  the  membranes,^  and,  from  its  large  size  and  conical 
shape,  will  form  a  still  more  efficient  haemostatic,  by  compressing 
the  placenta,  while  it  is  impossible  for  it  to  be  expelled  until  the 
OS  is  dilated,  and  thus  it  affords  a  greater  security  against  haemor- 
rhage. But,  for  the  introduction  of  this,  the  os  must  be  large 
enough  to  admit  two  fingers,  and  the  labour  therefore  advanced 
enough  for  bipolar  version.  If  the  bag  does  not  completely  arrest 
haemorrhage  a  weight  of  2  lb.  may  be  attached  to  the  neck  of  it 
by  a  string  and  hung  on  a  pulley  over  the  edge  of  the  bed. 

Hydrostatic  dilators  are  also  useful  when  the  membranes  are 
already  ruptured  and  haemorrhage  continues,  in  order  to  secure  a 
sufiicient  dilatation  of  the  cervix  to  allow  internal  version  or  the 
application  of  forceps. 

Rupture  of  the  Membranes. — This  method  is  applicable  to  cases 
of  partial  placenta  praevia,  especially  those  in  which  haemorrhage 
is  not  great,  and  active  labour  pains  have  already  commenced.  It 
may  be  adopted  more  safely  when  dilatation  of  the  os  has  made 
some  progress,   so  that  it  may  be  followed  up  soon,  if  necessary, 

1  Blacker,  Tniris.  Obst.  Koc.  London,  1«97,  Vol.  XXXIX.,  p.  138. 


6o6 


The  Practice  of  Midwifery. 


either  by  the  application  of  forceps,  or  version  by  the  internal 
method.  In  suitable  cases  it  has  the  advantage  that  the  chance 
for  the  child's  life  is  greater  than  if  version  is  performed.  The 
uterus  may  act  vigorously  as  soon  as  the  liquor  amnii  has  escaped, 
press  the  placenta  against  its  wall,  and  rapidly  complete  delivery, 

or,  if  it  does  not,  forceps  may  be 
applied,  or  Champetier  de  Ribes' 
dilator  used  if  the  os  is  not  yet 
large  enough  for  forceps. 

Digital  Separation  of  Pla- 
centa.— If  the  placenta  remains 
partially  attached  round  the 
whole  circuit  of  the  os,  the  pro- 
cess of  dilatation  is  retarded 
by  the  attachment.  The  total 
amount  of  haemorrhage  also 
appears  to  be  less  when  the  de- 
tachment is  rapid,  than  when  it 
takes  place  slowly  in  successive 
portions,  for  thrombosis  quickly 
occurs  in  the  part  which  has 
been  separated.  There  is  often 
an  advantage,  therefore,  in  com- 
plete placenta  prsevia,  in  aiding 
the  detachment  by  sweeping 
round  the  finger  inside  the  os. 

Performance  of  Version. — The 
traditional    treatment    for   pla- 
centa prsevia  is  the  performance 
^,    x^  of  version;  and  the  employment 

^^"•^^  of  the  method  of  bipolar  version 

Fig.  314.— Half  breech  forming  a  plug  after  renders  it  possible  to  adopt  this 
version,  in  a  case  of  placenta  prajvia.  treatment    at    an    early    stage, 

(Modified    from     Plates     XXIV.     and  .  ,,  *^  ^. 

XXVI.  Leopold,  Uterus  und  Kind.)        namely,  as  soon  as  ttie  cervix 

will  admit  two  fingers.  The 
majority  of  cases  of  placenta  prsevia  in  the  Guy's  Hospital  Lying-in 
Charity  have  been  treated  in  this  manner.  In  most  cases  of  placenta 
prsevia  bipolar  version  is  available  when  the  patient  is  first  seen. 

The  performance  of  version  is  by  far  the  most  effectual  means 
of  arresting  hsemorrhage  in  placenta  prsevia.  When  one  leg  is 
brought  down  the  half-breech  forms  a  plug  in  the  lower  segment 
of  the  'uterus,  and  presses  the  placenta  against  the  uterine  wall, 
so  that  there  is  hardly  ever  any  haemorrhage  of  consequence  after- 


Haemorrhage  in  Pregnancy.  607 

wards.  At  the  same  time  the  greater  part  of  the  liquor  amnii 
■will  have  escaped,  and  the  uterus  will  be  stimulated  by  complete 
contact  with  the  trunk  and  head  of  the  foetus.  There  is  no 
necessity  to  hasten  delivery  by  any  forcible  traction  of  the  leg, 
a  proceeding  which  might  cause  laceration  of  the  cervix  and 
subsequent  septic  absorption,  or  even  additional  bleeding  from  the 
torn  cervix. 

It  is  of  the  utmost  importance  to  allow  the  child  after  version  to 
be  delivered  by  the  natural  forces,  since  any  attempt  at  forcible 
delivery  is  almost  certain  to  be  followed  by  laceration  of  the  cervix 
or  lower  uterine  segment  and  the  danger  of  severe  post-partum 
hsemorrhage  and  subsequent  septic  infection.  The  danger  of  such 
lacerations  is  especially  great  in  placenta  prsevia,  because  of  the 
rigidity  of  the  portion  of  the  uterine  wall  to  which  the  placenta  is 
attached. 

The  method  of  performing  bipolar  version  will  be  described  in 
Chapter  XXXIV.  In  this  case,  if  the  os  is  wholly  covered  by 
placenta,  the  hand  is  passed  up,  on  the  side  where  separation  is 
greatest,  between  the  placenta  and  the  uterine  wall  till  the  mem- 
branes are  reached.  In  the  case  of  a  very  central  placental  inser- 
tion, it  may  be  necessary,  before  performing  the  actual  version,  to 
rupture  the  membranes  along  the  edge  of  the  placenta,  .to  draw 
that  edge  down  towards  the  centre  of  the  os,  and  then  proceed 
with  the  version  as  rapidly  as  possible.  If  the  cervix  is  already 
dilated  enough  to  allow  the  whole  hand  to  pass,  the  operator  may 
turn  by  the  internal  method  if  he  finds  it  easier. 

Unless  the  alternative  of  using  Champetier  de  Eibes'  bag  is 
adopted,  in  order  to  give  a  better  chance  of  life  to  the  child, 
version  should  be  performed  in  all  cases  of  complete  placenta 
prgevia,  and  in  cases  even  of  partial  placenta  prsevia  if  haemorrhage 
is  serious.  The  more  placenta  there  is  over  the  os,  and  the  less 
active  the  uterus,  the  greater  is  the  indication  for  version.  If 
version  is  likely  to  be  called  for,  it  is  better  not  to  puncture  the 
membranes  till  the  operator  is  ready  to  j)erform  it,  because  other- 
wise it  probably  cannot  afterwards  be  carried  out  by  the  bipolar 
method. 

The  chief  drawback  to  version  in  placenta  prsevia  is  that  it 
increases  the  risk  to  the  child,  which  is  likely  to  be  ah'eady 
enfeebled  by  partial  asphyxia  owing  to  the  placental  detachment 
and  uterine  haemorrhage.  On  this  account,  when  the  child  is  alive 
and  near  full  term,  the  placenta  prsevia  is  partial,  the  haemorrhage 
moderate,  and  the  uterus  beginning  to  act,  preference  may  be  given 
to   rupture   of   the   membranes   followed   by   the   introduction   of 


6o8  The  Practice  of  Midwifery. 

Champetier  de  Kibes'  bag,  and  delivery  by  forceps  or  version  when 
the  cervix  is  sufficiently  dilated. 

Application  of  Forceps. — If  the  membranes  have  been  ruptured, 
if  the  OS  is  sufficiently  dilated,  the  placenta  not  too  much  in  the 
way,  if  labour  is  not  progressing  fast,  and  some  haemorrhage 
continues,  the  best  mode  to  complete  delivery  is  to  put  on  forceps, 
drawing  the  placenta  down  to  one  side.  The  main  advantage  of 
this  treatment,  as  compared  with  version,  is  that  the  chance  of 
saving  the  child  is  greater. 

Csesarean  section,  both  vaginal  and  abdominal,  has  been  recom- 
mended for  placenta  praevia.  The  former  operation  is  only 
mentioned  to  be  condemned.  Cases  may  very  rarely  be  met  with 
of  placenta  previa  complicated,  for  example,  by  the  presence  of 
fibroid  tumours^  in  the  uterus,  or  in  an  elderly  primipara  with 
extreme  rigidity  of  the  cervix,  in  which  the  performance  of  a 
Caesarean  section  will  in  suitable  surroundings  entail  no  greater 
danger  to  the  mother  than  version  or  the  employment  of  a  hydro- 
static dilator,  and  in  which  the  danger  for  the  child  certainly  will 
be  lessened  by  such  an  operation.  In  such  circumstances,  and  in 
such  circumstances  only,  Caesarean  section  would  be  justifiable. 

In  the  management  of  the  third  stage  of  labour  great  care  must 
be  taken  to  avoid  the  occurrence  of  post-partum  haemorrhage,  and 
the  placenta,  which  is  often  torn,  must  be  examined  with  special 
attention  to  ensure  that  no  part  of  it  has  been  retained. 

HiEMOEEHAGE    FEOM    SePAEATION    OF    A    NOEMALLY    SITUATED 

Placenta,  oe  Accidental  H^moeehagb. 

Causation. — Accidental  haemorrhage  rarely  happens  to  primi- 
parae,  and  is  most  common  in  debilitated  women,  and  those  who 
have  had  many  children.  This  is  an  indication  that  there  is 
generally  some  morbid  condition  of  the  uterus,  such  as  chronic 
endometritis,  of  varying  origin,  or  placenta,  as  a  predisposing  cause. 
Such  predisposing  causes  are  similar  to  those  which  cause 
haemorrhage  and  abortion  in  the  earlier  months,  namely,  all 
diseased  conditions  of  the  placenta  which  cause  undue  vascular 
tension,  or  weakness  of  the  vessels  or  of  the  placental  attachment. 
In  some  cases  albuminuria  has  been  recorded.  Generally  there  is, 
in  addition,  some  exciting  cause.  This  may  be  direct  violence  to 
the  abdomen,  or  a  fall  or  shock,  or  excessive  muscular  exertion, 
such  as  lifting  weights.  Sometimes  there  is  only  an  emotional 
cause,  which  probably  acts  by  exciting  violent  or  irregular  con- 

1  Munro  Kerr,  Lancet,  October  30,  1909,  p.  1282. 


Haemorrhage  in  Pregnancy. 


609 


tractions  of  the  uterus.     In  comparatively  rare  cases  there  is  no 
obvious  exciting  cause.     In  some  instances  a  shght  effusion  of  blood 
under  the  placenta,  due  to  some  diseased  placental  condition,  may 
excite  irregular   uterine  con- 
traction   leading    to    further 
separation  of  the  placenta  and 
haemorrhage. 

Pathological  Anatomy. — 
From  partial  detachment  of 
the  placenta,  blood  is  poured 
out  between  the  placenta  and 
the  uterus.  In  most  cases 
this  blood,  or  some  part  of  it, 
reaches  the  edge  of  the  pla- 
centa, separates  also  the  mem- 
branes, and  escapes  at  the  os 
uteri.  Frequently  a  consider- 
able amount  of  clot  remains 
behind  within  the  uterus, 
behind  the  placenta,  or  be- 
tween the  membranes  and 
the  uterine  wall.  The  placenta 
may  be  hollowed  out,  so  as  to 
present  a  concave  surface  out- 
ward, if  the  clot  lies  mainly 
behind  it.  A  comparatively 
rare  variety  is  concealed  acci- 
dental hcemorrhage,  in  which 
no  blood,  or  scarcely  any, 
makes  its  appearance  exter- 
nally. Of  82  cases  recorded 
by  Colclough  6  were  of  this 
character,  and  41  of  200  col- 
lected by  Holmes. 

If  the  placenta  remains 
attached  at  its  margin  at  all 
parts,  a  considerable  amount 

of  blood  may  be  poured  out  behind  it,  without  any  at  all  reaching 
the  exterior.  Or  the  blood  may  be  retained  near  the  fundus,  between 
the  membranes  and  the  uterus,  the  uterus  not  acting  strongly,  and 


Fig.  315. — Section  of  the  uterus  of  a  patient 
who  died  of  internal  and  external  liEemor- 
rhage  when  SJ  months  pregnant,  with 
premature  separation  of  the  placenta  from 
shortness  of  the  cord  which  is  coiled  round 
the  child 's  neck.  The  placenta  is  separated 
entirely,  the  membranes  ruptured  artifi- 
cially, and  the  liquor  amnii  has  escaped. i 


I'inaid  et  Varnicr,  Etudes  d'Anatomie  Obstetrical,  18!)2. 


81) 


6io  The  Practice  of  Midwifery. 

the  chorion  remaining  undetached  in  the  lower  segment  of  the 
uterus.  The  uterus  may  be  distended  by  the  blood  and  clots  effused, 
especially  in  the  concealed  variety  of  accidental  haemorrhage.  In 
some  cases  the  distension  has  even  been  sufficient  to  rupture  the 
uterus.  In  general  the  amnion  is  not  ruptured,  and  no  blood  finds 
its  way  into  the  amnial  cavity.  Sometimes,  however,  rupture  does 
occur  from  the  placenta  or  elsewhere,  and  one  variety  of  concealed 
accidental  haemorrhage  may  thus  arise,  the  blood  passing  into  the 
amnial  cavity  instead  of  escaping  externally.  In  the  majority  of 
cases  accidental  haemorrhage  occurs  before  there  is  any  sign  of 
labour,  but  sometimes  the  bleeding  commences  in  the  early  stage 
of  labour,  or  at  any  rate  becomes  manifest  first  at  that  time.  It 
has  already  been  explained,  in  the  description  of  placenta  praevia 
(see  p.  599),  that,  in  a  certain  number  of  cases  ranked  as  acci- 
dental haemorrhage,  there  is  a  predisposing  cause  for  separation  in 
the  placenta  being  attached  low  down  in  the  uterus,  not  within  the 
zone  of  unavoidable  detachment,  but  in  the  intermediate  or  dan- 
gerous zone,  where  the  placenta  is  put  to  some  slight  strain  in 
dilatation  of  the  cervix,  and  receives  shocks  communicated  through 
the  cervix  more  directly  than  when  implanted  near  the  fundus 
uteri. 

Symptoms  and  Course. — The  symptoms  are  those  produced 
by  haemorrhage,  sometimes  accompanied  by  pain  from  distension 
of  the  uterus.  The  majority  of  the  cases  are  comparatively  mild, 
but  in  the  severe  cases  the  anaemia  and  prostration  are  apt  to  be 
greater  even  than  in  placenta  praevia,  since  the  placenta  may  be 
sej)arated  more  suddenly  and  widely.  Symptoms  of  collapse,  with 
failure  of  pulse,  are  most  marked  of  all  in  the  cases  of  concealed 
accidental  haemorrhage.  The  jDatient  may  die  from  haemorrhage 
undelivered.  As  in  placenta  j)raevia,  post-partum  haemorrhage  is 
also  more  liable  to  occur  than  usual,  on  account  of  the  patient's 
exhaustion,  and  death  shortly  after  delivery  is  not  uncommon. 

Diagnosis. — When  blood  and  clots  appear  externally,  the  dis- 
tinction has  to  be  made  from  placenta  praevia.  A  probable  diagnosis 
may  be  made  when  there  has  been  a  blow,  fall,  or  other  exciting  cause 
for  accidental  haemorrhage.  Even  in  the  absence  of  external 
exciting  cause,  serious  haemorrhage  usually  occurs  more  suddenly 
than  in  placenta  praevia,  without  previous  slighter  haemorrhages. 
A  positive  diagnosis  is  made  when  the  cervix  is  open  enough  to 
admit  the  finger,  and  no  placenta  is  found  within  reach.  If  the 
cervix  is  undilated,  there  is  a  jDresumption  against  placenta  praevia 


Haemorrhage  in  Pregnancy. 


6ii 


if  the  head  can  be  felt  normally  from  the  vagina  through  the 
uterine  wall.  Examination  of  the  membranes  after  delivery  will 
generally  show  whether  the  placental  insertion  encroached  upon 
the  dangerous  zone.  Assuming  that  the  membranes  were  punctured 
or  gave  way  near  the  centre  of  the  os  uteri,  the  aperture  in  the 
membranes  will  be  found  to  be  nearer  than  usual  to  the  margin  of 


Fig.  316. — Section  of  uterus  from  patient  dying  at  8th  month  of  eclampsia. 
There  is  a  large  intro-placental  hsematemia  about  half  the  area  of  the 
placenta  being  separated  from  its  site.  Partial  separation  of  the  mem- 
branes is  seen  in  the  lower  uterine  segment.     (Winter. i) 

the  placenta  at  some  part,  if  the  placental  insertion  has  been  lower 
down  in  the  uterus  than  usual. 


Concealed  accidental  hsemorrhage  may  be  difficult  to  diagnose,  if 
no  blood  whatever  escapes  externally.  The  chief  signs  to  judge  by 
are  sudden  collapse  and  faintness,  feeble  rapid  pulse,  some- 
times vomiting,  accompanied  by  general  appearance  of  anaemia,  and 


1  Zwel  Medlanschnitte  durch  Gebarende,  Berlin,  189ii. 


39—2 


6i2  The  Practice  of  Midwifery. 

great  tenderness  of  the  uterus.  The  uterus  on  palpation  will  be 
more  uniformly  tense  than  usual,  not  much  varying  in  firmness  by 
rhythmical  contraction,  and  the  foetal  parts  as  a  rule  cannot  be  felt, 
and  the  foetal  heart  sounds  often  cannot  be  heard.  Sometimes  it 
may  be  recognised  as  increased  in  size  from  the  effusion  into  it, 
especially  if  full  term  is  not  yet  nearly  reached,  as,  for  instance,  at  the 
sixth  month.  The  collapse  may  be  out  of  all  proportion  to  the 
amount  of  blood  effused,  and  is  in  part  due  to  the  shock  caused  by 
the  sudden  over-distension  of  the  uterus.  Concealed  accidental 
hasmorrhage  has  to  be  distinguished  from  rupture  of  the  uterus,  but 
rupture  is  not  likely  to  occur  to  a  normal  uterus  (except  from  great 
direct  violence)  before  the  onset  of  labour,  or  even  before  escape 
of  the  liquor  amnii.  In  cases  of  accidental  haemorrhage,  mainly  of 
a  concealed  character,  there  is  often  a  slight  escape  of  blood  per 
i-aginam,  which  reveals  the  real  nature  of  the  case.  Other  cases, 
more  frequent  than  those  of  concealed  haemorrhage,  are  of  mixed 
character.  There  is  considerable  external  haemorrhage,  but  the 
uterus  also  shows  signs  of  over-distension  by  clot  or  blood. 

Prognosis. — The  milder  cases  nearly  always  do  well,  but  in  the 
graver  ones  the  risk  of  death  directly  from  haemorrhage  is  even 
greater  than  in  placenta  praevia.  Out  of  49,145  deliveries  in  the 
Guy's  Hosj^ital  Lying-in  Charity  there  were  105  cases  of  accidental 
haemorrhage  reported  as  compared  with  92  of  placenta  praevia 
but  probably  many  slighter  cases  are  not  included  in  the  statistics. 
There  were  12  deaths  from  haemorrhage  reported  as  compared  with 
8  directly  due  to  haemorrhage  in  placenta  praevia,  or  11'4  per 
cent.  Of  the  more  serious  cases,  the  children  were  still-born  in 
about  60  per  cent.  The  risk  to  the  child  is  therefore  not  much  less 
than  in  placenta  praevia,  and  in  severe  cases  it  is  probably  greater. 
Johnston  and  Sinclair  recorded  only  4  deaths  of  mothers  in  81 
cases  at  the  Eotunda  Hospital,  or  4*9  per  cent.  The  cases  of 
concealed  accidental  haemorrhage  are  relatively  rare;  there  was  only 
1  in  the  105  cases  above  mentioned  in  the  Guy's  Hospital  Charity. 
A  considerable  number,  however,  has  been  recorded,  and  Goodell^ 
in  1870  collected  106.  In  these,  the  mortality  to  the  mothers  was 
nearly  51  per  cent.  ;  to  the  children  94  per  cent.  In  200  additional 
cases  collected  by  Holmes-  in  1901,  the  mortality  to  the  mothers 
was  32*2  per  cent,  to  the  children  85*8  per  cent.  Concealed 
accidental  haemorrhage  is  therefore  much  more  dangerous  to  both 

1  Amer.  Journ.  Obst.,  1869-70,  Vol.  II.,  p.  281. 

2  "Ablatio  PlacentjB,"  Amer.  Journ.  Obst.,  1901,  Vol.  XLIV.,  p.  753. 


Haemorrhage  in  Pregnancy.  613 

mother  and  child  than  accidental  haemorrhage  in  general.  The 
reason  probably  is  partly  that  the  element  of  shock  through  disten- 
sion of  the  uterus  is  superadded,  and  partly  that  the  very  fact  of  the 
uterus  allowing  such  distension  proves  that  its  walls  are  feeble,  or 
not  prone  to  contract. 

Treatment. — In  considering  the  treatment  of  cases  of  accidental 
haemorrhage  it  must  be  remembered  that  in  the  severe  cases  the 
foetal  mortality  will  always  be  very  high,  and  therefore  but  little 
regard  should  be  paid  to  preserving  the  life  of  the  child.  It  must 
also  be  borne  in  mind  that  the  object  of  most  of  the  methods  of 
treatment  employed  is  to  set  up  uterine  contractions,  and  so  to 
cause  constriction  of  the  bleeding  vessels  and  arrest  of  the 
haemorrhage.  When  it  is  impossible  to  evoke  uterine  contractions, 
then  the  same  result  is  sought  to  be  obtained  by  mechanical 
pressure,  as,  for  example,  in  plugging  the  vagina  and  applying  an 
abdominal  binder,  or  by  direct  ligation  of  the  vessels,  as  in 
Caesarean  section. 

In  slight  cases  occurring  during  pregnancy  it  will  be  sufficient  to 
keep  the  patient  in  bed  and  to  administer  an  opiate.  In  more 
severe  cases,  where  it  is  necessary  to  adopt  active  measures  to  arrest 
the  haemorrhage,  the  treatment  will  depend  upon  the  conditions 
present.  If  the  patient  is  in  labour,  uterine  contractions  occurring 
and  fairly  well  marked,  if  she  is  not  collapsed  and  the  cervix  soft 
and  partly  dilated,  the  membranes  may  be  ruptured.  Ergot  should 
be  given  at  the  same  time,  eitber  a  hypodermic  injection  of 
ergotin  or  ernutin,  or  a  drachm  of  the  liquid  extract,  repeated  if 
necessary.  It  is  advisable  also  to  give  a  hypodermic  injection  of 
strychnine.  The  membranes  should  be  ruptured  with  a  sound  or  a 
catheter  stylet.  If  the  abdominal  pressure  is  slight,  very  little 
liquor  amnii  may  escape  till  the  uterus  contracts.  But  the  operator 
should  not  be  satisfied  till  he  sees  enough  fluid  to  convince  him 
that  the  membranes  are  really  ruptured.  After  the  puncture  of  the 
membranes,  the  uterus  should  be  stimulated  by  external  pressure 
and  friction,  or  by  a  binder.  The  patient  should  be  kept  in  bed, 
and  the  position  should  be  the  dorsal  position  rather  than  the 
lateral,  to  promote  the  stimulating  pressure  upon  the  cervix,  and 
prevent  blood  collecting  at  the  fundus.  Frequently,  after  the  escape 
of  the  liquor  amnii,  the  uterus  acts  well,  and  haemorrhage  is 
arrested.  If  pains  are  feeble  from  exhaustion,  or  bleeding  con- 
tinues, labour  should  be  accelerated  by  forceps  if  the  os  is  dilated 
enough,  and  the  head  can  be  easily  reached.  If  the  child  is  dead, 
craniotomy,  followed  ])y  extraction  with  the  cephalotribe,  will  some- 


6 14  The  Practice  of  Midwifery. 

times  enable  the  labour  to  be  completed  more  rapidly,  with  a  less 
complete  dilatation  of  the  os.  Care  must  be  taken  not  to  empty 
the  uterus  too  rapidly,  and  to  keep  the  fundus  well  stimulated 
by  external  pressure  at  the  final  stage  of  delivery. 

If  the  haemorrhage  is  severe,  and  either  external  or  partly 
external  and  internal,  there  is  always  a  danger  that  the  uterus  may 
not  contract  if  the  membranes  are  ruptured.  In  such  a  case  when 
the  cervix  is  undilated,  the  cervical  canal  not  obliterated,  and 
uterine  contractions  absent,  and  especially  if  the  patient  is  collapsed, 
it  is  better  treatment  to  plug  the  vagina  so  long  as  the  membranes 
are  unruptured. 

In  the  first  edition  of  the  present  work,  published  in  1886,  plug- 
ging the  vagina  was  recommended  for  the  treatment  of  accidental 
haemorrhage  when  the  cervix  was  undilated  and  labour  had  not 
commenced.  The  same  treatment  was  advocated  by  Spiegelberg, 
and  had  been  recommended  as  early  as  1776.  Most  authorities, 
however,  considered  that  it  was  dangerous,  on  the  ground  that  fatal 
bleeding  might  take  place  into  the  uterus  behind  the  plug.  The 
fact  that  concealed  accidental  haemorrhage  proves  much  more 
dangerous  than  ordinary  accidental  haemorrhage,  was  thought  to  be 
a  strong  confirmation  of  this  view.  In  concealed  accidental 
haemorrhage,  however,  the  element  of  danger  lies,  not  in  the  blood 
being  unable  to  escape,  but  in  the  uterus  being  so  inert  that  it 
allows  itself  to  be  distended  without  expelling  the  blood. 

More  recently,  Smyly  has  introduced  into  the  practice  of  the 
Rotunda  Hospital,  Dublin,  the  treatment  of  plugging  the  vagina, 
combined  with  a  tight  abdominal  binder  and  pressure  from  a 
perineal  pad,  for  those  cases  of  accidental  haemorrhage  in  which  the 
OS  uteri  is  undilated  or  little  dilated,  and  labour  pains  are  absent  or 
slight.  Experience  appears  to  justify  this  treatment,  which  is 
now  generally  accepted.  It  is  found  that  after  a  few  hours  the 
patient  rallies,  if  much  collapsed,  and  that  good  labour  pains 
come  on. 

Colclough^  records  forty-three  cases  treated  at  the  Rotunda 
Hospital  by  plugging,  with  two  deaths  (or  4'6  per  cent.),  one  from 
rupture  of  uterus.  The  plugging  must  be  carried  out  in  the 
manner  described  for  the  case  of  placenta  praevia  (see  p.  604),  and 
it  must  be  remembered  that  the  treatment  is  a  dangerous  one  in 
unskilful  hands,  if  either  the  plugging  is  not  effective,  or  antisepsis 
not  fully  maintained.  It  is  available  only  when  the  membranes  are 
unruptured. 

*  "  Accidental  HEemorrhage,"  Journ.  of  Obst,  and  Gyn.  Brit.  Emp.,  August,  1902, 
Vol.  II.,  No.  2,  p.  153. 


Haemorrhage  in  Pregnancy.  615 

According  to  the  Eotunda  practice,  the  plugs  are  left  for  twenty- 
four  hours,  unless  there  is  haemorrhage  through  them,  or  they 
commence  to  bulge  from  the  onset  of  labour  pains.  If  there  is 
hsemorrhage,  it  is  regarded  as  a  sign  that  the  plugging  has  not  been 
efficiently  done,  and  the  plugs  are  reapplied.  At  the  end  of  twenty- 
four  hours  they  are  removed,  the  vagina  is  douched,  and,  if  labour 
pains  have  not  come  on,  the  plugs  are  reinserted.  In  only  three 
cases  out  of  thirty-six  (Colclough)  was  delivery  postponed  over 
twenty-four  hours  from  the  application  of  the  plug. 

It  is  thus  proved  that  plugging  the  vagina  is  a  good  treatment, 
but  it  is  not  yet  finally  demonstrated  that  it  is  better  than  the  other 
method.  The  statistics  given  above  may  be  compared  with  those 
of  eighty-one  cases  of  accidental  haemorrhage  out  of  13,748 
deliveries  recorded  by  Sinclair  and  Johnston.^  These  were  treated 
at  the  Rotunda  Hospital  by  early  puncture  of  membranes,  with 
acceleration  of  labour  by  forceps  or  version.  In  one  case  only  the 
vagina  was  plugged  by  a  sponge.  There  were  four  deaths  (4*9  per 
cent.),  in  two  only  of  which  death  was  due  directly  to  hsemorrhage. 

The  statistics  of  the  results  of  treatment  by  plugging  are  very 
slightly  better  than  those  of  the  old  method,  not  more  than  might 
be  expected  from  the  effect  of  modern  improvements  in  antiseptic 
midwifery.  The  above  sets  of  statistics  are  strictly  comparable, 
both  being  from  the  Rotunda  Hospital.  More  extensive  statistics 
are  required  to  decide  the  question. 

If  the  bleeding  is  severe,  the  membranes  are  ruptured,  and  the 
liquor  amnii  has  escaped,  there  is  much  greater  risk  of  fresh  haemor- 
rhage taking  place  into  the  uterine  cavity  behind  a  plug  than  while 
the  membranes  are  intact.  It  is  not  therefore  advisable  to  plug  the 
vagina  in  such  a  case.  If  the  cervical  canal  is  intact,  but  will 
admit  two  fingers,  a  Champetier  de  Ribes'  bag  should  be  intro- 
duced, and  a  weight  of  2  lb.  attached  to  it  by  a  string  and  hung 
over  the  edge  of  the  bed.  Care  must  be  taken  to  watch  the  con- 
dition of  the  fundus,  to  see  that  no  progressive  distension  is  going 
on.  The  bag  itself  by  its  bulk  takes  the  place  to  a  great  extent  of 
the  liquor  amnii  in  filling  the  uterine  cavity,  and  it  is  a  very 
powerful  stimulus  to  uterine  contraction,  having  a  superiority  in 
this  respect  over  a  vaginal  plug.  If  the  cervix  will  not  admit  two 
fingers,  it  must  be  dilated  until  it  will  do  so  either  digitally  or  with 
Rossi's  or  other  instrumental  dilator  (see  Chapter  XXVII.),  before 
the  Champetier  de  Ribes'  bag  is  applied. 

The  case  is  one  of  extreme  difficulty  and  danger  if  the  Champetier 

1  Practical  Midwifery,  Dublin,  18.'58, 


6i6  The  Practice  of  Midwifery. 

de  Eibes'  bag  fails  to  cause  uterine  contractions  and  dilatation  of 
the  cervix,  and  to  arrest  the  hgemorrhage.  It  has  been  proposed  in 
such  conditions  to  carry  out  forcible  dilatation  of  the  cervix  with 
Bossi's  or  some  similar  mechanical  dilator  or  by  rajjid  manual 
dilatation,  and  to  deliver  either  by  the  application  of  forceps,  by 
version,  or,  as  the  child  is  practically  always  dead,  after  craniotomy 
or  embryotomy.  The  results  of  this  method  of  accouchement  force 
are,  however,  exceedingly  bad,  and  it  cannot  be  recommended.  It  is, 
nevertheless,  the  onl}^  resource  when  the  patient  is  so  situated  as 
not  to  allow  of  the  performance  of  Csesarean  section,  either  vaginal 
or  abdominal.  Such  cases  as  these  present  one  of  the  most  difficult 
problems  in  obstetrics,  and  the  maternal  mortality,  whatever  the 
treatment,  will  always  be  very  high. 

Cases  of  severe  concealed  internal  haemorrhage  are  both  very 
dangerous  and  very  difficult  to  treat,  dangerous  because  of  the 
marked  shock  and  collapse  usually  associated  with  them,  and 
difficult  to  treat  because  the  uterine  muscle  as  a  rule  is  so  paralysed 
that  all  attempts  to  set  up  uterine  contractions  are  futile.  If  the 
method  of  plugging  the  vagina,  together  with  the  use  of  a  tight 
abdominal  binder,  acts  purely  by  mechanically  compressing  the 
uterus,  as  Colclough  maintains,  then  it  would  appear  to  be  a  suitable 
method  of  treating  these  cases.  Smyly,  however,  and  others  of  the 
Dublin  school,  do  not  recommend  it,  but  prefer  Csesarean  section. 
The  latter  operation,  followed  by  removal  of  the  uterus  by  supra- 
vaginal amputation,  would  certainly  appear  to  be  the  best  method 
of  treatment.  In  this  way  alone  is  it  possible  to  deliver  the  patient 
rapidly  and  at  the  same  time  to  arrest  the  haemorrhage  with 
certaint}'. 

Abdominal  Ceesarean  section,  which  has  been  j^erformed  success- 
fully in  this  class  of  case,  is  preferable  to  vaginal,  although  the 
latter  is  strongly  recommended  by  Diihrssen^  and  others. 

When  accidental  haemorrhage  has  occurred,  special  care  must  be 
taken  in  the  third  stage  of  labour  to  avoid  jjost-partum  haemorrhage. 

1  Diihrssen  ;  V.  W^inckel,  Handbuch  der  Geburtshiilfe,  Vol.  III.,  Th.  1,  s.  595. 


Chapter  XXVI. 
PRECIPITATE  AND  PROLONGED  LABOUR, 

Precipitate  Labour. 

Labour  may  be  precij)itate  when  the  expulsive  force  is  unusually 
powerful  in  proportion  to  the  resistance  to  be  overcome.  Excess 
in  the  force  of  the  pains  has  to  be  considered,  not  absolutely  in 
itself,  but  in  relation  to  the  resistance  and  the  strength  of  the 
resisting  tissues.  Thus  precipitate  labour  may  take  place  when 
the  expulsive  force  is  normal,  if  there  is  unusually  small  resistance 
from  large  relative  size  of  the  pelvis  and  softness  or  dilatability  of 
soft  parts.  It  may  also  happen  with  normal  resistance  if  the 
expulsive  force  is  excited  to  excessive  action  by  undue  reflex  irrita- 
bility, and  again  with  resistance  above  the  normal,  and  a  still 
greater  excess  of  irritability. 

Precipitate  labour  depending  on  smallness  of  resistance,  though 
described  as  an  abnormality,  has  rarely  any  ill  effect.  In  such  a 
case  the  passage  of  the  child  may  take  place  in  a  few  minutes. 
The  chief  risks  to  be  feared,  therefore,  are  the  inconvenience  of 
delivery  taking  place  suddenly  and  unexpectedly,  and  the  danger 
to  the  child  from  its  being  born  in  some  unusual  position.  In  such 
cases  the  child  has  been  expelled  into  the  pan  of  a  water-closet. 
Still  more  frequently  it  has  been  born  when  the  mother  was  stand- 
ing upright,  and  fallen  upon  the  floor,  breaking  the  funis.  Even 
then  the  injury  suffered  by  the  child  has  generally  not  been  so 
severe  as  might  be  expected,  for  the  fall  is  broken  by  the  resistance 
of  the  funis,  and  when  the  funis  is  thus  violently  torn  across, 
bleeding  generally  does  not  take  place  from  the  severed  end.  There 
appears  to  be  a  somewhat  greater  risk  of  the  uterus  becoming 
relaxed  after  delivery,  and  allowing  haemorrhage,  when  it  has  not 
been  called  fully  into  activity  by  a  reasonable  amount  of  resistance. 
Even  this  result,  however,  is  exceptional,  and  more  usually  the 
uterus  contracts  well  after  rapid  labour. 

The  risks  are  greater  when,  with  a  normal  or  an  excessive 
resistance,  the  expulsive  force  is  excited  to  undue  degree  by  un- 
usual reflex  irritability,  or  by  injudicious  administration  of 
oxytocics,  such  as  ergot.  There  may  be  excess  of  intensity  in  the 
action  of  the  uterus  itself,  or  of  the  auxiliary  muscles,  or  of  both 


6i8  The  Practice  of  Midwifery. 

together.  Or  again,  the  usual  intervals  of  rest  between  the  pains 
may  fail,  and  the  pains  may  follow  each  other  in  stormy  succession, 
almost  without  intermission,  especially  as  the  final  stage  of  labour 
approaches.  The  chief  danger  of  excessive  intensity  in  the 
expulsive  force  is  that  of  laceration  either  of  the  cervix  or  perineum, 
the  soft  parts  having  no  time  to  dilate  under  the  influence  of 
repeated  and  moderate  pains.  Sometimes  even  rupture  of  the 
uterus  involving  the  peritoneum  may  occur,  though  no  bony  obstruc- 
tion exists.  If  there  is  moderate  pelvic  obstruction  fracture  of 
the  cranial  bones  of  the  child  may  be  produced.  From  excessive 
straining  in  bearing  down,  emphysema  of  the  neck,  face,  and  chest 
is  sometimes  produced,  from  rupture  of  some  air  vesicles  in  the  lung. 

When  pains  come  on  in  rapid  stormy  succession,  they  are 
generally  also  intense  in  degree,  and  a  similar  danger  of  laceration 
exists.  There  is  also  danger  of  the  child  becoming  asphyxiated 
from  the  pressure  upon  it  not  being  relieved  by  intermissions. 
Intense  mental  excitement  is  sometimes  produced  by  the  rapid 
succession  of  agonising  pains,  and  this  may  even  amount  to 
temporary  mania,  so  that  a  patient  is  not  responsible  for  her 
actions. 

In  some  cases,  following  the  rapid  emptying  of  the  uterus  and  the 
sudden  fall  in  the  intra-abdominal  pressure,  a  syncopal  attack 
may  occur. 

Treatment. — If  precipitate  labour  from  deficient  resistance  is 
anticipated,  the  only  treatment  necessary  is  to  keep  the  patient 
continually  recumbent  in  the  lateral  position  from  the  commence- 
ment of  pains,  and  to  be  careful  to  secure  adequate  uterine  con- 
traction after  delivery.  If  the  expulsive  force  is  excessive,  and 
threatens  laceration,  it  is  also  well  to  keep  the  patient  in  the 
lateral  or,  still  better,  the  semi-prone  position,  so  that  the  pressure 
on  soft  parts  may  not  be  assisted  by  gravity.  Over-action  of  the 
auxiliary  muscles  may  be  kept  in  check  to  a  considerable  extent 
by  voluntary  control.  The  patient  should  not  have  any  support 
to  hold  to  by  the  hands,  or  press  against  with  the  feet,  and  should 
be  exhorted  not  to  hold  her  breath,  but  to  cry  out  during  the 
height  of  a  pain.  The  most  effective  remedy,  however,  for  ex- 
cessive action  both  of  the  uterus  and  auxiliary  muscles  is  the 
administration  of  chloroform.  By  this  means  the  pains  may  be 
moderated  to  any  desired  extent.  Failing  chloroform,  a  sub- 
cutaneous injection  of  morphia  may  be  given,  but  it  is  not  so 
efi"ective.  Chloroform  will  equally  moderate  an  unduly  rapid  suc- 
cession of  pains,  and  abolish  the  nervous  excitement   therefrom 


Precipitate  and  Prolonged  Labour.         619 

resulting.  When  the  obstacle  lies  at  the  vaginal  outlet  and  peri- 
neum, especially  in  primiparte,  and  excessive  or  rapidly  following 
pains  threaten  laceration,  the  perineum  may  often  be  saved  by 
delaying  the  advance  of  the  head  in  the  manner  previously 
described  (see  page  302).  This  is  greatly  facilitated  if  the  patient  is 
under  chloroform,  since  otherwise  she  is  likely  to  lose  self-control 
at  the  height  of  a  pain,  and  throw  herself  into  such  a  position  that 
the  physician  is  powerless. 

Prolonged  Labour. 

Labour  may  be  prolonged  by  an  absolute  inefficiency  in  the 
expulsive  force,  or  by  an  insuperable  resistance  in  the  pelvis  or 
soft  parts.  In  the  majority  of  cases  of  prolonged  labour,  however, 
there  is  only  a  relative  disproportion  between  the  force  and  the 
resistance.  The  resistance  is  greater  than  normal,  and  the  force, 
either  from  the  first  {primary  inertia),  or  when  the  patient  is 
beginning  to  get  exhausted  from  her  efforts  {secondary  inertia),  is 
insufficient  to  overcome  it  within  a  moderate  time.  In  primiparae, 
even  the  resistance  of  the  vaginal  outlet  and  perineum  not  uncom- 
monly is  sufficient  to  produce  this  effect,  the  pains,  which  at  first 
may  have  been  satisfactory,  becoming  inefficient  after  a  time. 

GeneralEffectsof  Protracted  Labour. — Undue  prolongation  of 
labour  always  increases  the  risk  to  the  mother,  even  when  the  pro- 
longation is  only  in  the  first  stage,  at  which  it  is  of  comparatively 
slight  consequence.  There  is  a  certain  similarity  in  the  symptoms 
which  arise  in  prolonged  labour,  whatever  the  cause  of  prolongation. 
They  depend  in  some  degree  upon  the  continuous  pressure  exerted 
by  the  foetus,  but  to  a  much  greater  extent  upon  the  effect  upon  the 
nervous  system  of  the  fruitless  efforts  of  the  uterus.  If  the  delay 
depends  only  upon  feeble  pains  {'primary  inertia),  and  especially 
when  this  is  the  case  in  the  first  stage  of  labour  before  rupture  of 
the  membranes,  a  very  long  time  may  elapse  before  serious  efforts 
become  manifest.  The  more  vigorous  are  the  fruitless  efforts  of  a 
strongly  acting  uterus  to  overcome  an  obstacle,  the  more  quickly 
do  the  grave  constitutional  effects  of  exhaustion  appear  {secondary 
inertia).  The  first  marked  effect  is  upon  the  pulse,  which,  instead 
of  being  only  moderately  accelerated  during  the  pains,  as  by 
muscular  exertion  of  any  other  kind,  gradually  rises  above  the  rate 
of  100  per  minute,  and  eventually  to  a  rate  of  120  or  more.  In 
cases  of  obstructed  labour  the  patient  becomes  anxious,  distressed 
and  restless,  the  copious  lubricating  secretion  from  the  cervix  and 


620  The  Practice  of  Midwifery. 

vulva  fails,  and  the  parts  become  dry  and  hot,  often  swollen. 
Eventually  even  a  slough  may  form  at  the  part  most  exposed  to 
pressure.  The  tongue  becomes  coated,  and  finally  dry  and  black. 
The  temperature  rises,  and  nausea  and  vomiting  are  often  marked. 
Eventually,  within  a  limited  number  of  hours,  the  patient  would 
sink  from  exhaustion,  the  pulse  becoming  progressively  feebler  and 
more  rapid.  Of  these  symptoms  the  earlier,  and  especially  the 
acceleration  of  the  pulse,  should  always  be  a  sufficient  indication 
for  interference,  and  the  more  formidable  ones  should  never  be 
allowed  to  arise. 

Tetanic  Contraction  or  Continuous  Action  of  the  Uterus. — The 
effect  upon  the  uterus  itself  is  one  of  the  utmost  importance  to 
recognise.  For  a  considerable  time  a  strongly  acting  uterus  is 
stimulated  by  resistance  to  more  vigorous  pains.  Eventually, 
however,  if  it  is  unable  to  overcome  the  obstacle,  that  is  in  obstructed 
labour,  and  no  rupture  occurs,  the  pains  appear  to  become  feebler 
and  cease.  The  uterus,  however,  does  not  usually  become  lax,  but 
gets  into  a  state  of  continuous  or  tetanic  contraction,  unbroken  by 
any  rhythmical  pains,  so  that  it  feels  firm  and  hard  when  the  hand 
is  placed  upon  the  abdomen.  The  useless  energy  expended  in  such 
tetanic  contraction  still  further  exhausts  the  nervous  system.  It 
has  moreover  the  efi'ect  that,  i£  all  the  liquor  amnii  has  escaped, 
the  parts  of  the  uterine  wall  in  contact  with  projections  of  the  foetus 
are  subjected  to  prolonged  pressure,  while  those  parts  which  corre- 
spond to  dejDressions  and  are  so  relieved  from  pressure,  become 
intensely  congested. 

"While  a  strongly  acting  uterus  will  fall  at  length  into  this  state 
of  tetanic  action,  if  the  obstacle  is  insuperable,  a  feebly  acting 
uterus  may  do  so  at  a  much  earlier  period.  Thus  in  many  cases 
which  were  formerly  regarded  as  simply  "  powerless  labour,"  the 
condition  is  really  one  of  continuous  action  of  the  uterus.  Cases 
of  true  inertia  alone,  either  primary  or  secondary,  are  distinguished 
by  the  softness  and  laxity  of  the  uterus,  and  by  the  fact  that  the 
pulse  is  only  slightly  accelerated,  whereas  in  continuous  action  it 
is  always  markedly  so.  As  a  rule,  it  is  only  in  the  second  stage  of 
labour,  and  after  the  rupture  of  the  membranes,  that  tetanic  con- 
traction of  the  uterus  is  apt  to  come  on.  In  very  exceptional  cases, 
however,  it  may  do  so  even  in  the  first  stage,  when  there  is  an 
insuperable  obstacle  to  dilatation  of  the  os,  such  as  cancer  or 
cicatricial  closure.  In  some  such  cases,  continuous  action  may 
even  supervene  without  any  vigorous  rhythmical  pains  ever  having 
been  apparent.  Any  degree  of  this  continuous  action  or  "tetany  " 
of  the  uterus,  associated  with  cessation  of  rhythmical  pains,  should 


Precipitate  and  Prolonged  Labour.         621 

be  an  immediate  indication  for  affording  assistance.  It  is  an 
absolute  contra-indication  to  the  administration  of  any  oxytocic,  as 
ergot. 

Retraction  of  the  Uterus. — Besides  the  constitutional  symptoms, 
protracted  labour,  unless  due  to  primary  or  secondary  inertia  of  the 
uterus,  tends  to  produce  a  certain  local  effect.  The  effect  of 
repeated  pains,  if  they  are  unable  to  cause  advance  of  the  foetus,  is 
to  stretch  gradually  more  and  more  the  cervix  together  with  the 
adjoining  lower  segment  of  the  uterus.  In  corresponding  degree 
the  strong  muscular  portion  of  the  upper  segment  of  the  uterus 
retracts,^  shrinks,  and  becomes  thicker,  while,  by  gradual  escape  of 
the  liquor  amnii,  it  more  closely  grasps  the  foetus.  The  consequence 
is  that  both  the  internal  os  uteri  and  the  retraction  ring  or  line  of 
demarcation  between  the  retractile  and  extensible  portions  of  the 
body  of  the  uterus  (the  so-called  ring  of  Bandl,  according  to  some 
authorities)  travel  gradually  upward.  One  of  these,  generally 
regarded  as  being  the  retraction  ring,  may  sometimes,  after  pro- 
tracted labour,  be  felt  on  external  examination  as  a  transverse  line 
of  depression  across  the  abdomen,  some  distance  above  the  pubes. 
If  such  a  line  is  detected  at  a  considerable  height  above  the  pubes, 
it  is  an  indication  both  that  interference  is  required,  and  that  the 
case  has  advanced  too  far  for  version.  When  retraction  has  pro- 
ceeded beyond  a  certain  point,  the  power  of  the  uterus  is  practically 
lost,  notwithstanding  the  thickening  of  its  walls  produced,  as  the 
muscular  fibres,  having  already  shortened  themselves  to  a  con- 
siderable extent,  are  no  longer  able  to  contract  with  any  degree  of 
force. 

Eetraction  is  generally  the  sequel  of  active  expulsive  pains  ;  but  if 
the  uterus  is  emptied  artificially  in  the  absence  of  pains  it  may 
occur  without  them,  the  uterus  gradually  closing  up  its  cavity. 
The  force  of  retraction  increases  with  time,  and  offers  a  powerful 
resistance  to  dilatation  when  it  has  been  established  a  considerable 
time. 

The  extensile  zone,  as  it  is  stretched,  eventually  undergoes 
dangerous  thinning.  This  may  lead  at  last  to  rupture,  com- 
mencing in  the  thinned  portion,  but  extending  perhaps  beyond  its 
limits.  The  internal  os  uteri  may  travel  so  far  upward  as  to  pass 
above  the  head  of  the  foetus,  even  when  this  is  prevented  from 
descending  far  into  the  brim.  It  may  then  contract  somewhat 
around  the  neck,  being  the  part  of  the  uterus  which  has  the 
strongest  circular  muscular  fibres.     If  version  is  attempted  in  this 

1  "Retraction"  means  the  contiactioa  and  shortening  of  the  uterine  muscle,  not 
followed  by  relaxation. 


622 


/, 


The  Practice  of  Midwifery. 

state  of  affairs  there  is  great  danger  of  laceration, 
since,  to  elevate  the  head,  it  is  necessary  to  push 
it  past  a  constricting  ring.  In  the  frozen  section 
(Fig.  131,  p.  220)  if  the  ridge  marked  at  o  i  is 
really  the  internal  os,  as  held  by  Braune,  its 
position  appears  to  indicate  protraction  of  labour, 
though  the  membranes  are  intact.  As  a  rule  the 
excessive  retraction  of  the  muscular  portion  of 
the  uterus  occurs  only  after  rupture  of  the  mem- 
branes, when  the  advance  of  tlie  foetus  is  ob- 
structed. In  rare  cases  it  may  happen  even  in 
the  first  stage,  when  pains  of  fair  strength  have 
been  long  continued,  but  some  j)owerf ul  resistance 
to  dilatation  of  the  external  os  exists.  When  this 
is  so,  protraction  even  of  the  first  stage  becomes 
serious. 

Effects  produced  at  the  Several  Stages  of  Lahour. 
— The  first  stage  of  labour,  before  escape  of  the 
liquor  amnii,  may  be  protracted,  sometimes  even 
for  several  days,  without  very  serious  effect  to 
either  mother  or  child,  both  being  protected  from 
undue  pressure  by  the  equable  support  of  the 
liquor  amnii.  If  protraction  is  only  due  to  uterine 
inertia  at  this  stage,  the  patient  suffers  little 
more  than  the  eflect  of  fatigue  and  loss  of  sleep. 
If  it  is  due  to  rigidity  or  other  morbid  condition 
of  the  cervix,  the  constitutional  effects  of  pro- 
tracted labour  come  on  sooner  or  later.  Pro- 
tracted labour  in  the  first  stage,  after  premature 
rupture  of  the  membranes,  is  much  more  serious. 
The  life  of  the  child  is  endangered  by  prolonged 
pressure,  the  greater  part  of  the  liquor  amnii 
gradually  draining  away.  The  futile  efforts  of 
the  uterus  also  at  length  bring  on  the  symp- 
toms of  nervous  exhaustion  already  described. 


Fig.  317. — Section  of  a  portion  of  the  uterine  wall  and  vagina 
from  a  patient  who  died  during  labour.  The  thickened 
iipper  uterine  segment,  Bandl's  ring  forming  a  thickening 
on  the  uterine  wall,  and  the  greatly  stretched  and  dis- 
tended lower  uterine  segment  measuring  eight  inches  in 
length,  are  shown.  A  small  part  of  the  placenta  is  seen 
attached  at  the  upper  end  of  the  section. i 


1  Univ.  Coll.  Hosp.  Med.  School  Mus.  No.  4,252. 


Precipitate  and  Prolonged  Labour.         623 

Much  longer  delay  can,  however,  be  tolerated  with  impunity  at 
this  stage  than  later  on,  both  by  mother  and  child.  The  child 
suffers  less  because  there  is  less  powerful  reflex  stimulus  to  uterine 
action  than  when  the  head  is  resting  upon  the  vagina  or  perineum, 
the  mother  for  the  same  reason,  and  also  because  the  vaginal 
tissues  are  not  yet  endangered  by  pressure  of  the  head,  lying 
deeply  in  the  pelvis.  In  pelvic  and  face  presentations,  labour, 
especially  in  its  earlier  stage,  is  naturally  more  protracted,  and  less 
harm  than  usual  results,  particularly  in  pelvic  presentations,  since 
the  shaj)e  of  the  presenting  part  causes  less  pressure. 

Protraction  of  the  second  stage,  after  the  external  os  uteri  is 
completely  retracted  over  the  head,  is  the  most  serious  of  all,  and 
produces  grave  symj)toms  within  a  very  few  hours.  Sloughing  is 
especially  likely  to  occur  at  the  anterior  vaginal  wall,  if  delay  is 
allowed  to  continue  very  long,  and  to  be  followed  by  vesico-vaginal 
fistula.  Delay  at  this  stage  is  also  most  likely  to  prove  fatal  to  the 
child  through  asphyxia.  It  is  in  these  circumstances  that  the 
modern  practice  of  giving  much  more  frequent  assistance  by 
forceps  than  was  usual  in  former  days  is  both  most  beneficial,  and, 
at  the  same  time,  free  from  any  difficulty  or  danger. 

Anomalies  of  the  Expulsive  Fokce. 

Inertia  of  the  Uterus. — Feebleness  of  uterine  action  may  be 
either  due  to  deficient  nerve  force  dependent  upon  some  constitu- 
tional debility,  or  to  faulty  development,  weakness,  or  degenerative 
changes  of  the  uterine  muscle.  The  latter  condition  is  itself 
generally  dependent  upon  the  constitutional  state.  Inertia  may 
therefore  result  from  any  exhausting  disease,  from  constitutional 
debility,  from  any  cause  of  malnutrition,  such  as  vomiting,  or  from 
residence  in  a  hot  climate.  As  might  be  expected,  it  is  more 
common  among  women  of  the  upper  classes,  not  accustomed  to 
much  muscular  exertion,  than  among  women  used  to  hard  work. 
On  the  other  hand,  it  is  common  among  the  poor  who  are  unable  to 
get  sufficient  nourishment,  especially  if  resident  in  towns,  and 
leading  sedentary  lives.  If  pregnancy  occurs  in  very  young  girls, 
the  uterus  is  apt  to  be  insufficiently  developed.  This  may  also 
occur  if  women  much  beyond  the  usual  age  become  pregnant  for 
the  first  time,  but  is  not  then  so  usual.  A  distended  bladder  or 
loaded  rectum  often  interferes  with  the  development  or  continuance 
of  effective  rhythmical  pains.  The  influence  appears  to  act  to  a  great 
extent  through  the  nervous  system,  though  it  is  also  partly 
mechanical,  especially  in  the  case  of  a  distended  bladder,  which  is 


624  The  Practice  of  Midwifery. 

a  direct  impediment  to  the  action  of  the  auxiliary  forces.  Excess  of 
liquor  amnii  or  twin  pregnancy  also  tends  to  produce  inertia,  the 
over-distended  and  therefore  thinned  uterine  wall  being  naturally 
more  feeble  in  its  contraction. 

The  so-called  "  polarity  of  the  uterus,"  or  correlation  between 
the  condition  of  the  body  of  the  uterus  and  that  of  the  cervix, 
according  to  which  a  quiescent  state  of  the  body  of  the  uterus  is 
associated  with  muscular  tonicity  of  the  cervix,  and  active 
expulsive  pains  with  physiological  relaxation  of  the  circular 
muscular  fibres  of  the  cervix,  has  already  been  explained  (see 
pp.  210,  211). 

In  consequence  of  this  correlation  it  happens  that,  in  the  first 
stage  of  labour,  inertia  of  the  uterus,  or  a  tendency  to  tonic  con- 
traction instead  of  active  rhythmical  pains,  is  apt  to  be  brought 
about  if  the  natural  mechanism  of  dilatation  of  the  cervix  does  not 
act  satisfactorily.  The  cause  may  be  a  want  of  the  natural  pro- 
jection of  the  bag  of  membranes,  either  from  deficiency  of  liquor 
amnii,  inelasticity  of  membranes,  or  their  adhesion  around  the  os, 
or  again  it  may  be  premature  rupture  of  the  membranes,  rigidity 
of  the  cervix  from  some  previous  morbid  state,  or  spasm  of  it  set  up 
by  over-frequent  examinations  or  any  other  cause. 

There  may  also  be  a  secondary  inertia  in  the  second  stage  of 
labour,  when  some  obstruction  exists,  such  as  the  rigidity  of  soft 
parts  in  a  primipara,  and  a  weak  uterus,  easily  wearied  by  its 
efforts,  falls  into  a  state  of  laxity  when  it  fails  to  overcome  the 
obstruction.  The  term  inertia  should  not,  however,  be  applied  to 
the  more  dangerous  condition  of  continuous  action  or  tetanic 
contraction  (see  p.  620)  supervening  upon  obstructed  labour. 

Irregular  and  Painful  Uterine  Contractions. — The  amount 
of  pain  produced  by  uterine  contraction  is  by  no  means  propor- 
tional to  its  mechanical  power,  which  must  be  estimated  by  its  effect 
upon  the  bag  of  membranes,  or  presenting  part.  Not  uncommonly 
contractions  are  excessively  painful  at  the  same  time  that  they  are 
inefficient.  This  character  in  the  pains  may  last  throughout  the 
whole  labour,  and  in  such  case  it  may  depend  either  upon  the 
neurotic  over-sensitive  character  of  the  nervous  system,  or  upon 
some  inflammatory  or  other  morbid  condition  of  the  walls  of  the 
uterus.  Women  who  have  previously  suffered  from  dysmenorrhoea 
mainly  of  the  neuralgic  or  neurotic  type  are  liable  to  be  affected  in 
this  way.  The  excessively  painful  character  of  the  contractions 
seems  itself  directly  to  impair  their  efficiency,  especially  by  its 
interference  with  bearing-down  efforts. 


Precipitate  and  Prolonged  Labour.         625 

There  is  another  kind  of  excessive  painfulness  in  the  uterine 
action,  depending  upon  the  nature  of  the  contraction  itself,  which 
is  irregular  and  cramp-like,  affecting  the  uterus  unequally,  and  so 
producing  little  or  no  effect  upon  the  os  uteri  or  presenting  part. 
A  part  of  the  distress  occasioned  by  such  pains  is  the  consciousness 
of  the  patient  herself  that  they  are  useless.  Irregular  contractions 
occur  especially  in  the  first  stage  of  labour.  Women  of  over- 
sensitive nervous  system  are  more  prone  to  them,  as  they  are  to 
the  merely  over-painful  contractions.  They  are  liable  to  be  set 
up  by  any  source  of  reflex  irritation  acting  upon  the  nervous 
system,  such  as  indigestion,  or  a  loaded  rectum.  One  variety 
constitutes  the  well-known  "  spurious  pains "  coming  on  before 
the  real  onset  of  labour,  and  producing  no  effect  upon  the  cervix. 
These  are  generally  dispelled  by  an  aperient.  Irregular  contrac- 
tion may  also  be  set  up  in  the  first  stage,  when  there  is  something 
to  interfere  with  dilatation  of  the  cervix,  such  as  morbid  adhesion 
of  the  membranes  around  the  os,  or  rigidity  of  the  cervix ;  some- 
times also  even  in  the  second  stage,  when  the  uterus  finds  itself 
unequal  to  resistance  with  which  it  meets. 

Inefficiency  in  the  Auxiliary  Forces.— Although  the  action 
of  the  uterus  is  the  most  important  part  in  labour,  yet,  when  the 
resistance  is  somewhat  greater  than  usual,  a  deficient  action  of  the 
auxiliary  muscles  may  be  of  considerable  consequence,  partly  from 
the  fact  that  the  bearing-down  efforts  act  as  a  stimulus  also  to  the 
uterus  itself.  This  deficiency  occurs  when  there  is  any  affection 
of  heart  or  lungs,  which  prevents  the  patient  holding  her  breath  in 
order  to  fix  the  diaphragm  and  bear  down ;  when  the  abdominal 
walls  have  been  overstretched  by  previous  pregnancies,  or  by  any 
other  cause ;  and  when  ascitic  fluid,  or  tumours  of  any  kind,  are 
present  in  the  abdomen.  The  auxiliary  forces  may  also  be  feeble 
from  muscular  weakness,  or  when  the  patient  is  so  deficient  in  self- 
control  and  so  unable  to  bear  pain  that  she  persists  in  crying  out 
even  in  the  pains  of  the  expulsive  stage,  and  will  not  hold  her 
breath  to  bear  down. 

Deviation  of  the  Uterine  Axis.— There  is  generally  some 
obliquity  of  the  uterus  toward  the  right  side,  but  in  some  cases 
lateral  obliquity  is  excessive.  A  more  important  and  common 
deviation  is  anteversion  of  the  uterus,  depending  upon  undue  laxity 
in  the  abdominal  walls,  found  chiefly  in  women  who  have  had 
many  previous  pregnancies.  The  fundus  may  then  hang  forward 
and  even  downward  over  the  pubes,  so  that  the  presenting  part  is 

M.  40 


626  The  Practice  of  Midwifery. 

directed  backward  against  the  sacrum  or  lumbar  vertebrae  instead 
of  toward  the  pelvis.  Deviation  of  the  uterine  axis  is  of  com- 
paratively little  consequence  until  the  membranes  are  ruptured. 
After  this,  the  efficacy  of  the  force  in  causing  advance  of  the  foetus 
is  reduced  in  proportion  to  the  cosine  of  the  angle  of  deviation. 
Additional  pressure,  both  useless  and  injurious,  is  called  out,  equal 
to  the  product  of  the  force  and  the  sine  of  the  same  angle.  In  this 
■way,  in  anteversion  of  the  uterus,  if  a  sudden  pain  occurs  when  the 
patient  is  upright,  it  may  even  cause  rupture  of  the  vagina  or  cervix 
at  its  posterior  part,  without  the  existence  of  any  considerable 
obstruction. 

Treatment  in  the  First  Stage  of  Labour. — The  main  remedies 
for  uterine  inertia  in  the  first  stage,  while  the  membranes  are 
intact,  are  time  and  patience.  Investigation  should  first  be  made 
as  to  the  presence  of  any  source  of  reflex  disturbance  capable  of 
removal.  Thus  the  effect  of  a  copious  enema  is  often  very  satis- 
factory. Beyond  this,  the  chief  jDoints  to  be  attended  to  are  to 
keep  up  the  strength  of  the  patient  by  a  sufficient  amount  of  food, 
and  to  secure  her  a  reasonable  amount  of  sleep.  For  this  purpose 
a  dose  of  opium  or  chloral  may  be  administered.  Pains  often 
diminish  from  the  effect  of  fatigue,  and,  after  a  sleep,  return  with 
renewed  vigour.  In  the  intervals  the  patient  should  be  up  and 
moving  about  as  much  as  possible,  not  continually  reclining. 
When  she  lies,  the  dorsal  position  should  be  preferred,  so  as  to 
secure  the  greatest  pressure  upon  the  cervix.  If  the  contractions 
are  irregular  and  unusually  painful  as  well  as  inefficient,  chloral 
should  be  administered  in  the  mode  already  described  (see  p.  315). 
In  the  case  either  of  spasmodic  irregular  pains,  or  of  great  pro- 
traction of  the  first  stage,  especially  if  the  bulging  of  the  bag  of 
membranes  is  not  satisfactory,  it  is  well  to  make  sure  that  the 
membranes  are  separated  from  the  uterine  wall  for  some  distance 
within  the  os.  If  any  adhesion  exists,  artificial  separation  will 
often  considerably  accelerate  labour.  To  do  this,  two  joints  or 
the  whole  length  of  the  index  finger  should  be  passed  within  the 
OS  and  swept  round  in  a  circle.  In  multiparse,  when  the  vagina  is 
capacious,  the  half  or  whole  hand  may  be  passed  into  the  vagina 
to  carry  this  out.  Otherwise  the  patient  should  be  placed  on  her 
back,  the  fundus  pushed  somewhat  backward,  and  the  cervix 
drawn  forward  by  the  index  finger  hooked  into  it,  until  it  is  near 
enough  for  the  finger  to  sweep  round  the  anterior  segment.  If 
the  posterior  segment  cannot  be  reached  by  the  finger,  a  large 
gum  elastic  catheter  guided  by  a  strong  stylet  having  only  a  slight 


Precipitate  and  Prolonged  Labour.         627 

curve,  both  sterilised  by  boiling  water,  may  be  used  for  this  part, 
care  being  taken  not  to  rupture  the  membranes. 

If  the  OS  is  soft  and  dilatable  in  a  case  of  inertia,  and  especially 
if  it  is  suspected  that  the  liquor  amnii  is  excessive,  it  often 
accelerates  matters  to  puncture  the  membranes  rather  before  full 
dilatation  of  the  os  has  been  reached.  Nothing,  however,  calls  for 
more  judgment  and  experience  than  the  decision  when  this  can  be 
done  with  advantage.  If  the  membranes  are  ruptured  prematurely 
in  an  unsuitable  case,  the  os  may  become  rigid  from  spasm,  lubri- 
cating secretion  may  fail,  and  the  case  be  much  more  protracted, 
and  the  patient  suffer  much  more,  than  she  would  otherwise  have 
done. 

If  there  is  rigidity  of  the  os  as  well  as  inertia,  so  long  protrac- 
tion must  not  be  allowed.  Artificial  dilatation  must  be  undertaken 
if  the  pulse  becomes  much  accelerated,  or  if  retraction  of  the 
uterus  becomes  manifested  by  a  transverse  line  of  depression  being 
felt  on  external  palpation.  If  the  liquor  amnii  has  escaped,  it  is 
still  more  necessary  not  to  allow  too  long  delay ;  but  here  also 
acceleration  of  the  pulse  will  be  the  most  valuable  guide.  The 
mode  of  interference  will  be  described  in  the  section  on  morbid 
conditions  of  the  cervix  (Chapter  XXVII.). 

Treatment  in  the  Second  Stage  of  Labour. — If  pains  are 
inefficient  in  the  second  stage,  care  should  be  taken  to  correct  any 
deviation  of  the  uterine  axis,  especially  anteversion.  If  anteversion 
exists,  the  fundus  should  be  supported  by  a  firm  binder,  and  the 
patient  should  lie  on  her  back.  The  dorsal  position  has  the 
advantage  in  all  cases  of  inertia,  at  any  rate  until  the  head  is 
passing  the  vulva ;  for  gravity  then  aids  the  advance  of  the  child, 
and  increases  the  pressure  on  soft  parts  and  thereby  reflex  stimulus. 
Examinations  may  also  be  made  with  advantage  more  frequently 
than  under  ordinary  circumstances,  provided  that  there  is  no  dry- 
ness or  swelling  of  the  soft  parts ;  for  the  pressure  of  one  or  two 
fingers  in  the  vagina,  and,  still  more,  the  pressure  on  the  perineum 
of  the  remaining  fingers  folded  back,  tend  to  increase  the  reflex 
stimulus  to  the  uterus. 

In  all  cases  of  marked  inertia  the  use  of  chloroform  should 
be  avoided  if  possible,  or  it  should  be  administered  very  spar- 
ingly, not  only  because  it  tends  to  prolong  labour  in  such 
cases,  Init  because  there  is  then  increased  risk  of  post-partum 
haemorrhage. 

External  Pressure. — A  valuable  mode  of  stimulation  is  the  use  of 
external  pressure.     This  has  been  employed  from  time  immemorial 

40—2 


628  The  Practice  of  Midwifery. 

by  various  savage  races,  often  by  very  rough  and  rude  methods. 
When  resistance  is .  slight  the  direct  effect  of  pressure  may  cause 
advance  of  the  foetus,  even  in  the  absence  of  a  pain,  but  the  chief 
vahie  of  the  method  is  its  stimulating  effect  upon  the  uterus.  It 
may  be  carried  out  when  the  patient  is  in  the  lateral  position,  but 
more  conveniently  when  she  lies  on  her  back.  Two  hands  are  laid 
upon  the  fundus  uteri,  and,  as  soon  as  the  first  hardening  of  the 
uterus  at  the  beginning  of  a  pain  is  felt,  it  is  stimulated  by  friction. 
At  the  height  of  the  pain  steady  pressure  is  made  downward  and 
backward  in  the  uterine  axis.  Some  patients  are  more  tolerant 
than  others  of  this  pressure,  and  it  must  not  be  carried  so  far  as  to 
give  great  pain.  The  same  process  is  repeated  with  each  succeeding 
pain.  Even  in  the  absence  of  pain,  friction  and  kneading  with 
moderate  pressure  may  be  used  at  intervals  of  a  few  minutes,  in 
the  hope  of  exciting  pains.  The  plan  is  only  to  be  adopted  when 
primarj^  inertia  is  the  sole  cause  of  delay,  not  when  there  is 
exhaustion,  continuous  action  of  the  uterus,  or  any  serious 
obstruction  to  delivery. 

Oxytocic  Drugs. — Of  the  various  drugs  rejDuted  to  cause  uterine 
contraction,  only  two  are  deserving  of  consideration  here,  namely, 
ergot  and  quinine.  In  former  days  when  the  application  of  forceps 
was  regarded  as  an  operation  very  rarely  to  be  undertaken,  ergot 
was  used  much  more  frequently  than  now.  There  are  several  dis- 
advantages in  its  use.  It  frequently  not  only  intensifies  the  pains, 
but  brings  on  a  tonic  contraction  of  the  uterus  in  the  intervals, 
which  greatly  increases  the  risk  of  the  child  dying  from  asphyxia. 
When  exhaustion  is  approaching,  it  may  simply  bring  on  the  state 
of  continuous  action,  without  increasing  the  rhythmical  pains  at  all. 
Children  stillborn  from  prolonged  labour  are  therefore  more 
frequent  in  the  practice  of  those  who  use  ergot  frequently,  and, 
moreover,  the  use  of  the  drug  involves  the  risk  of  inducing  that 
condition  of  continuous  uterine  action  which  is  now  well  recognised 
as  highly  dangerous  to  the  mother.  If  used  before  full  dilatation 
of  the  OS  and  its  retraction  over  the  head,  ergot  may  cause 
spasmodic  rigidity  ;  if  used  injudiciously,  when  any  obstruction 
exists,  it  may  cause  rupture  of  the  uterus.  The  only  case  in 
which  ergot  may  be  used  with  safety  is  when  it  is  quite 
certain  that  inertia  is  the  only  fault,  and  that  no  obstruction 
exists.  To  secure  this  condition,  the  patient  must  be  a  parous 
woman,  who  has  had  no  difficulty  in  previous  confinements, 
the  uterus  must  be  quite  lax  in  the  intervals  of  pains,  the  pelvis 
of  good  size,  the  os  fully  retracted  over  the  head,  the  head  easily 
movable,     and     with    no    considerable    caput    succedaneum,    the 


Precipitate  and  Prolonged  Labour.         629 

foetal  heart  unimpaired  in  force  and  frequency,  and  the  mother's 
pulse  quiet. 

Quinine,  given  in  a  full  dose  of  6  to  10  grains,  also  has  a 
stimulating  effect  upon  the  uterus,  and  is  less  likely  to  induce 
continuous  action  instead  of  expulsive  pains.  In  general,  therefore, 
it  may  be  used  in  jDreference  to  ergot,  when  uterine  inertia  is  the 
cause  of  delay.  If  ergot  is  used,  it  may  be  given  in  doses  of  30  to 
60  grains  of  the  powder,  made  into  fresh  infusion  with  boiling 
water,  or  30  to  60  minims  of  the  liquid  extract.  The  effect  of  any 
oxytocic  drug  generally  becomes  manifested  within  twenty  minutes 
or  half  an  hour.  If  any  has  been  administered,  the  condition  of  the 
patient  should  be  carefully  watched,  as  well  as  the  foetal  heart,  and 
the  physician  should  be  prepared  to  aid  delivery  with  forceps, 
within  a  moderate  time,  if  the  effect  of  the  drug  is  not  satisfactory 
or  sufficient. 

In  general,  ergot  should  be  reserved  for  the  purpose  of 
acting  upon  the  uterus  after  delivery,  at  which  time  its  pro- 
perty of  inducing  tonic  contraction  is  of  special  value  to  avert 
the  risk  of  haemorrhage.  When,  however,  uterine  inertia  through- 
out the  course  of  labour  has  been  so  marked  as  to  indicate 
a  risk  of  post-partum  haemorrhage,  or  when  a  patient  has  had 
serious  flooding  in  former  deliveries,  a  dose  of  ergot  may  with 
advantage  be  given  before  delivery,  in  two  conditions — first.  Just 
as  the  head  reaches  the  perineum,  when  there  is  no  prospect 
of  obstruction  at  that  stage ;  secondly,  just  before  the  application 
of  forceps,  when  it  has  been  decided  to  terminate  labour  by  their 
means. 

Application  of  Forceps. — In  the  great  majority  of  cases  of  pro- 
longed labour,  the  cause  lies  not  merely  in  uterine  inertia,  but  in 
some  degree  of  extra  resistance,  due  either  to  slight  disproportion 
between  the  foetal  head  and  the  pelvis,  or  rigidity  of  the  soft  parts, 
such  as  is  especially  frequent  in  primiparse.  In  these  circum- 
stances, the  administration  of  ergot  is  analogous  to  applying  a 
spur  to  the  already  overtaxed  uterus,  and  is  liable  to  end  in  a  still 
more  complete  exhaustion.  It  is  now  generally  agreed  that  it  is  a 
more  scientific  plan  to  supplement  the  insufficient  expulsive  force 
by  the  vis  a  fronte  exerted  by  means  of  forceps.  Even  if  the  only 
fault  is  inertia,  there  is  no  harm  in  extraction  by  forceps,  provided 
care  is  taken  to  secure  due  contraction  of  the  uterus  after 
delivery,  and  so  avoid  post-partum  haemorrhage.  It  is  not  now  a 
question  of  the  high  forceps  ojDeration,  in  cases  in  which  there  is 
an  obstruction  preventing  the  head  descending  into  the  pelvis,  or 
of  the  application  of  forceps  when  delay  is  due  to  the  failure  of 


630  The  Practice  of  Midwifery. 

the  cervix  to  dilate.  In  both  these  conditions  application  of  the 
forceps  is  a  much  more  serious  matter,  only  to  be  undertaken  for 
grave  reason.  But  when  the  head  has  entered  the  cavity  of  the 
pelvis  so  as  to  be  easily  grasped  by  the  forceps,  and  the  cervix  is 
either  completely  retracted  over  the  head,  or  so  far  dilated  that  it 
no  longer  offers  an  obstacle  to  delivery,  extraction  by  forceps  is  both 
easy  and  practically  almost  free  from  risk. 

Indications  for  Use  of  Forceps. — Kecourse  should  be  had  to  forceps 
long  before  any  of  the  graver  symptoms  of  protracted  labour, 
which  were  before  enumerated  (see  p.  623),  have  appeared.  Ac- 
celeration of  the  pulse  is  the  most  valuable  practical  indication 
of  the  necessity  for  interference.  The  minimum  j)ulse-rate,  taken 
in  the  intervals  of  pains,  is  the  rate  which  must  be  taken  as  a 
guide.  It  is  to  be  remembered  that  some  persons  have  habitually 
a  rapid  pulse,  especially  those  suffering  from  any  heart  affection, 
or  from  alcoholism.  These  cases  will  generally  be  distinguished 
by  the  pulse  having  been  rapid  from  the  very  outset  of  labour. 
It  must  also  be  remembered  that  a  rising  pulse  may  be  the  effect 
of  alcohol  given  during  labour  by  injudicious  friends.  Setting 
apart  these  cases,  it  may  be  said,  as  a  general  rule,  that  when  the 
pulse  has  risen  from  a  moderate  rate  to  exceed  100  per  minute  in 
the  second  stage  of  labour,  between  the  pains,  the  os  being  dilated, 
artificial  assistance  is  desirable.  One  case  must  be  excepted, 
namely,  that  in  which,  toward  the  end  of  labour,  vigorous  pains 
come  on  in  rapid  succession.  These  are  often  accompanied  by  a 
pulse  rising  to  a  high  rate,  simply  from  the  absence  of  intermissions. 
In  this  case  instrumental  interference  is  superfluous,  if  any  progress 
is  being  made,  for  the  labour  is  likely  soon  to  be  completed  by 
nature. 

Even  before  the  pulse  rises  sufficiently  to  indicate  a  necessity 
for  interference,  forceps  may  be  applied  with  advantage,  if,  after 
complete  retraction  of  the  cervix,  the  head  is  detained  for  any  long 
time,  more  than  two  hours  or  so,  in  the  vagina,  or  resting  on  the 
perineum,  and  little  or  no  progress  is  being  made.  Longer  time 
should  of  course  be  allowed  for  this  stage  in  primiparae  than  in 
parous  women,  since  in  the  former  longer  time  is  naturally  required 
for  the  dilatation  by  successive  pains  of  the  vaginal  outlet  and 
perineum,  and  laceration  is  more  likely  to  occur  if  this  time  is 
shortened.  If  the  head  fits  so  tightly  in  the  pelvis  that  it  does  not 
recede,  and  cannot  easily  be  pushed  back,  in  the  interval  of  pains, 
and  if  moreover  the  caput  succedaneum  is  large  and  increasing, 
these  conditions  form  additional  indications  in  favour  of  interfering 
without  waiting  long  for  constitutional  symptoms,  since  they  denote 


Precipitate  and  Prolonged  Labour.         631 

that  both  the  foetal  head  and  maternal  soft  parts  are  subjected  to 
serious  pressure. 

It  cannot  be  doubted  that,  by  the  modern  practice  of  having 
recourse  to  forceps  without  great  reluctance,  both  maternal  lives  are 
saved,  and  the  lives  of  children  which  would  have  been  stillborn  from 
prolonged  pressure.  In  the  present  day,  however,  there  is  probably 
little  need  to  urge  the  expediency  of  a  frequent  use  of  forceps,  but 
it  is  necessary  rather  to  caution  against  the  risk  of  carrying  the 
frequency  of  their  use  too  far  ;  for  practitioners  are  naturally  often 
exposed  to  the  temptation  to  apply  forceps  early,  in  order  to  save 
their  own  time.  In  this  view  it  must  be  remembered  that  the 
cases  which  try  the  patience  most  are  often  those  in  which  the 
delay  is  due  to  difficulty  in  the  complete  dilatation  and  retrac- 
tion of  the  cervix.  Although,  when  the  head  is  in  the  vagina, 
forceps  may  as  a  rule  be  applied,  even  unnecessarily,  with 
impunity,  this  is  not  the  case  when  the  cervix  is  not  fully 
dilated.  There  is  then  a  risk  of  cervical  laceration,  which  not 
only  involves  an  increased  chance  of  septic  absorption,  but  the 
prospect  that  the  patient  may  suffer  for  years  afterwards  from  the 
cervical  inflammation  consequent  upon  laceration  with  ectropion. 

Some  authorities,  in  urging  a  frequent  use  of  forceps,  have  based 
their  recommendation  upon  the  very  large  saving  of  foetal  life  said 
to  be  attained  thereby.  It  does  not  appear,  however,  that  there 
are  any  trustworthy  statistics  proving  that  any  such  large  saving 
can  be  obtained.  Of  the  total  number  of  still-births,  a  large 
proportion  are  in  cases  of  premature,  macerated,  or  syphilitic 
children,  or  the  result  of  malpresentation.  The  number  of  these 
may  vary  so  much  in  different  localities,  or  in  different  classes  of 
society,  that  any  inference  from  the  statistics  of  individual  jpracti- 
tioners  as  to  the  still-births  due  to  protracted  labour,  or  saved  by 
the  early  use  of  forceps,  becomes  difficult. 

Under  these  circumstances  it  is  of  interest  to  compare  the  results 
obtained  in  two  adjoining  districts,  among  populations  of  a  similar 
character,  namely,  the  Lying-in  Charities  of  Guy's  and  St.  Thomas's 
Hospitals.  Some  years  ago  forceps  were  used  more  than  ten  times 
as  often  in  the  St.  Thomas's  Charity  as  they  were  in  the  Guy's 
Charity.  Thus,  for  12  years  (1863—1875),  in  the  Guy's  Charity, 
the  forceps-rate  was  5*1  per  1,000  (about  1  in  200  deliveries) ;  the 
corresponding  rate  of  still-births  in  vertex  presentations,  2*7  per 
cent.  In  the  St.  Thomas's  Charity,  in  1874,  the  forceps-rate  was 
54*2  per  1,000  (about  1  in  18  deliveries) ;  the  corresponding  rate 
of  still-births  in  vertex  presentations,  2*8  per  cent.  In  1875,  the 
forceps-rate  was   61*8  jjer  1,000   (about   1   in   16  deliveries);   the 


632  The  Practice  of  Midwifery. 

corresponding  rate  of  still-births  in  vertex  presentations,  2*8  per 
cent.  In  the  above  ratios  of  still-births,  premature  and  macerated 
children  are  included.  It  therefore  appears  that,  though  no  one 
would  probably  now  recommend  for  private  practice  so  sparing  a 
use  of  forceps  as  only  one  forceps-case  in  200  deliveries,  yet  with 
this  a  slightly  better  ratio  of  still-births  was  attained  than  that  in 
the  St.  Thomas's  Charity  with  a  use  of  forceps  ten  or  twelve  times 
as  frequent.  No  patient  died  in  the  St.  Thomas's  Charity  in  these 
years  after  the  use  of  forceps,  so  the  practice  there  was  at  any  rate 
apparently  innocuous  to  the  mothers,  if  it  did  not  diminish  the 
ratio  of  still-births. 

A  similar  inference  may  be  drawn  from  the  statistics  of  the 
Rotunda  Hospital,  Dublin.  The  patients  may  be  presumed  to  have 
been  of  a  similar  class  at  different  times,  but  the  forceps-rate 
varied  very  widely  under  different  masters.  Under  Dr.  Shekleton 
(1847 — 1854),  the  forceps-rate  was  16'5  per  1,000  ;  the  total  ratio 
of  still-births,  6'9  per  cent.  Under  Dr.  G.  Johnston  (1871—1875), 
the  forceps-rate  was  116*4  per  1,000  ;  the  total  ratio  of  still-births, 
6*1  per  cent.  Excluding  premature  and  putrid  children.  Dr. 
Shelileton's  ratio  of  still-births  was  2*7  per  cent. ;  Dr.  Johnston's 
(1868 — 1875),  2-2  per  cent,,  with  an  average  forceps-rate  of  96*4 
per  1,000.  This  gives  an  apparent  gain  by  frequent  use  of  forceps 
of  one-half  per  cent.  But  the  greater  part  of  this  is  probably  due 
to  the  substitution  of  forceps  delivery  for  craniotomy,  Dr.  Johnston 
having  introduced  the  long  curved  forceps  in  place  of  the  straight 
forceps  previously  used  at  the  Eotunda  Hospital.  Thus  Dr. 
Shekleton  had  0'79  per  cent,  craniotomy  cases,  Dr.  Johnston  only 
0-35  per  cent.  If  the  difference  between  these  be  subtracted,  only  a 
difference  of  "06  per  cent,  in  the  ratio  of  still-births  remains  in 
favour  of  the  frequent  use  of  forceps. 

Neither  do  statistics  show  positively  any  saving  of  maternal 
mortality  by  a  forceps-rate  much  greater  than  about  1  in  200.  At 
the  Eotunda  Hospital,  under  Dr.  Shekleton,  with  a  forceps-rate  of 
16-5  per  1,000,  maternal  mortality  was  IS'O  per  1,000  ;  under  Dr. 
Johnston,  with  a  forceps-rate  of  96-4  per  1,000,  mortality  was  22-0 
per  1,000.  The  latter  high  mortality  was  mainly  due  to  puerperal 
septicaemia,  and  cannot  fairly  be  taken  as  telling  conclusively  against 
a  frequent  use  of  forceps.  In  the  Guy's  Charity  (1863—1875),  with 
a  forceps-rate  of  5-1  per  1,000,  mortality  was  4*4  per  1,000.  In  the 
St.  Thomas's  Charity,  in  1874,  with  a  forceps-rate  of  54*2  per  1,090, 
mortality  was  7*4  per  1,000;  in  1875,  with  a  forceps-rate  of  61-8  per 
1,000,  mortality  was  3'4  per  1,000;  giving  a  mean  mortality  for 
the  two  years  of  5*4  per  1,000. 


Precipitate  and  Prolonged  Labour.         633 

A  moderately  frequent  use  of  forceps,  in  cases  where  interference 
is  not  absolutely  required,  can  therefore  only  justly  be  recom- 
mended on  the  ground  that  it  shortens  the  patient's  suffering,  does 
not  increase  her  danger,  saves  the  practitioner's  time,  and  effects  a 
slight  saving  in  the  rate  of  still-births.  This  saving  is  so  slight  as 
to  suggest  that  delivery  by  forceps  must  in  itself  involve  some 
increased  risk  to  the  child,  counterbalancing  in  some  measure  the 
advantages  gained  by  shortening  the  labour. 

No  positive  general  rules  can  be  laid  down  as  to  the  frequency 
with  which  it  is  desirable  to  use  forceps,  since  much  depends  upon 
the  race  of  the  patients,  their  position  in  life,  and  other  circum- 
stances. The  results  of  the  St.  Thomas's  Charity  above  quoted 
appear  to  show  that  a  forceps -rate  as  high  as  1  in  16  or  1  in  18 
deliveries  does  not  endanger  the  mothers,  but  wider  statistics  on 
this  point  are  to  be  desired.^ 

In  20,604  labours  during  the  years  1883 — 1902  recorded  by 
V.  Winckel,^  forceps  were  applied  635  times,  a  forceps-rate  of  30*8 
per  1,000.  In  three-fourths  of  the  cases  the  indication  for  the 
use  of  the  forceps  was  afforded  by  interference  with  the  foetal 
circulation,  while  in  20  per  cent,  the  indication  lay  in  some  condi- 
tion of  the  mother,  such  as  swelling  of  the  soft  parts,  thinning  of 
the  lower  uterine  segment,  or  a  general  affection,  such  as  eclampsia, 
necessitating  assistance. 

In  about  10  per  cent,  of  the  cases,  the  indication  for  the  employ- 
ment of  the  forceps  was  afforded  by  both  the  mother  and  the  child. 
The  maternal  mortality  was  3*1  per  1,000,  and  the  morbidity  was 
11"1  per  cent.,  while  the  foetal  mortality  was  9"8  per  cent. 

In  the  Eotunda  Hospital  during  the  years  1896 — 1903,  among 
431  forceps  cases  in  11,098  labours,  or  a  forceps-rate  of  38  per  1,000, 
there  were  no  maternal  deaths,  but  a  fcetal  death-rate  of  13'9  per 
cent.^ 

J  See  papers  by  the  author  :  "  EfEects  of  a  Frequent  Use  of  Forceps  upon  the 
Fcetal  and  Maternal  Mortality,"  Obstet.  Journ.,  1877,  Vol.  V.  ;  "  Foetal  Mortality  in 
Obstetric  Practice,"  Obstet.  Journ.,  1878,  Vol.  VI. 

2  V.  Winckel,  "  Uber  die  Anzeigen  flir  die  Zangenoperation,"  Deutsche  Klinik,  1902, 
Vol.  IX.,  pp.  483—500. 

3  Jellett,  Manual  of  Midwifery,  190.5.  p.  1001. 


Chapter  XXVIL 

LABOUR    OBSTRUCTED    BY    ANOMALIES     OF    THE 

SOFT    PARTS. 

Spasmodic  Contraction  of  the  Cervix  Uteri — Trismus  Uteri. 
— The  strongest  circular  muscular  fibres  of  the  uterus  are  those  of 
the  cervix.  The  action  of  these  is  especially  marked  at  two  points, 
the  internal  and  the  external  os,  especially  the  former,  which  forms 
the  main  sphincter  of  the  uterine  cavity,  both  in  the  unimpregnated 
and  pregnant  condition.  In  normal  labour  at  full  term,  the 
internal  os  becomes  dilated,  either  before  manifest  pains  set  in,  or 
■with  the  earlier  pains.  It  is  therefore  chiefly  spasmodic  rigidity  of 
the  external  os  which  is  observed  as  a  cause  of  delay  in  the  first 
stage  of  labour.  In  premature  labour,  however,  and  more 
especially  when  labour  is  induced  prematurely,  as  in  the  case 
of  placenta  praevia,  eclampsia,  or  pelvic  contraction,  spasm  of  the 
internal  os  is  not  uncommonly  manifested.  This  is  not  so  likely  to 
hajjpen  when,  as  in  cases  of  pelvic  contraction,  there  is  time  to 
induce  labour  by  a  gradual  method,  imitating  as  closely  as  possible 
the  natural  process.  It  is  much  more  frequent  when,  as  in  the 
case  of  eclampsia,  the  process  has  to  be  made  a  rapid  one  on  account 
of  the  mother's  condition.  When  spasm  of  the  internal  os  does 
occur,  it  is  apt  to  cause  more  resistance  than  that  of  the  external 
OS,  since  the  muscular  fibres  are  more  powerful,  and  extend  over  a 
wider  space. 

Causation. — It  has  been  already  described  how  physiological 
relaxation  of  the  cervix  is  normally  associated  with  active  expulsive 
pains  (see  p.  210).  Minor  degrees  of  spasmodic  contraction  are 
therefore  very  common  as  a  cause  of  delay  in  the  first  stage  of 
labour  in  association  with  ineffective  jDains.  The  extreme  form  of 
spasmodic  rigidity,  which  has  been  called  "  trismus  uteri,"  and 
which  has  sometimes  persisted  as  an  obstruction  until  the  efi^ects 
of  the  delay  upon  the  patient  have  been  very  serious,  is  a  very 
rare  condition.  The  cause  of  spasm  of  the  cervix  may  sometimes 
be  simply  inertia  of  the  body  of  the  uterus.  More  frequently 
there  is  some  source  of  reflex  irritation  causing  both  one  and  the 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    635 

other,  and  to  this  women  of  a  sensitive  neurotic  disposition  are 
specially  liable. 

Thus  there  may  be  a  loaded  rectum  or  a  full  bladder,  or  pre- 
mature rupture  of  the  membranes,  interfering  with  the  normal 
mechanism  of  dilatation,  or  the  cause  may  be  too  frequent  digital 
examination  at  an  early  stage  of  labour,  or  premature  and 
ineffective  attempts  at  operative  interference.  Again,  the  cause 
may  be  extreme  painfulness  in  the  uterine  contractions,  due  to 
the  patient's  over-sensitiveness  to  pain,  or  some  previous  inflam- 
matory condition  of  the  uterine  walls.  Injudicious  administration 
of  ergot  in  the  first  stage  of  labour  may  have  the  same  effect ;  and 
so  may  malposition  of  the  foetus,  such  as  shoulder  presentation, 
when,  after  rupture  of  the  membranes,  it  prevents  the  presenting 
part  descending  into  the  cervix  to  continue  the  dilatation. 

Often  it  is  difficult  or  impossible  to  determine  how  much  of  the 
resistance  is  due  to  mere  rigidity  of  tissue,  how  much  to  muscular 
spasm.  It  is  probable  that  undue  organic  rigidity  is  often  the 
cause  of  superadded  spasm,  irritation  being  produced  by  delay  in 
the  first  stage.  If  the  os  suddenly  softens,  and  begins  to  dilate 
quickly,  with  the  accession  of  expulsive  pains,  it  is  proved  that  the 
previous  resistance  was  of  spasmodic  nature. 

Spasm  of  the  internal  os  is  generally  due  to  interference  with,  or 
curtailment  of,  the  natural  stage  of  preliminary  gradual  dilatation. 
When  there  is  any  source  of  irritation  to  the  uterus,  such  as  pro- 
longed labour  from  obstruction,  the  internal  os  may  contract  around 
the  neck,  above  the  head.  It  may  also  contract  around  the  body, 
or  neck,  after  delivery  of  the  breech,  in  pelvic  presentations,  or 
after  version.  After  delivery  a  similar  contraction  may  incarcerate 
the  placenta. 

The  very  severe  and  persistent  sj)asm  of  the  cervix,  which  has 
been  called  "trismus  uteri,"  has  been  sometimes  noted  in  cases  of 
placenta  prsevia.  The  organic  change  in  the  uterine  wall  near  the 
internal  os,  due  to  the  placental  implantation,  is  then  probably 
concerned  in  the  result.  It  has  also  occurred  in  some  cases  in 
which  the  membranes  have  been  injudiciously  ruptured  artificially 
in  a  protracted  first  stage. 

Organic  rigidity  of  the  cervix  may  be  due  to  inflammatory 
conditions  or  the  presence  of  new  growths.  Comparative  rigidity 
of  the  cervical  tissue  is  a  natural  condition  in  primiparae,  and  is 
the  cause  of  the  greater  length  of  the  first  stage  which  is  usual 
with  them.  In  parous  women,  it  is  usually  the  result  of  fibrous 
induration    and    hyperplasia    of     the    cervical    tissue    preceding 


636  The  Practice  of   Midwifery. 

pregnancy.  The  starting-point  of  this  has  often  been  bruising  in  a 
former  delivery,  or  laceration  followed  by  eversion.  Even  in 
primiparffi  there  may  be  fibroid  induration  resulting  from  cervical 
endometritis  or  chronic  engorgement,  and  rigidity  of  the  cervix  is 
more  likely  to  exist  if  pregnancy  occurs  for  the  first  time  late  in 
life.  There  is  a  special  form  of  cervical  hyperplasia  and  fibroid 
rigidity  depending  upon  procidentia  of  the  uterus  (or  prolapse  of 
the  second  degree)  previous  to  j)regnancy.  This  may  be  of  two 
forms,  either  elongation  with  hyperplasia  chiefly  of  the  supra- 
vaginal cervix,  which  is  consecutive  to  descent  of  the  cervix  external 
to  the  vulva,^  or  the  same  condition  of  the  vaginal  cervix,  which  is 
usually  primar}^,  and  a  cause  of  uterine  descent.  With  such  hyper- 
plasia of  cervix,  the  rigidity  may  involve  the  whole  length,  including 
the  internal  os.  In  rare  cases  it  is  difficult  to  overcome.  Thus  I 
have  been  compelled  from  this  cause  to  deliver  with  the  cephalotribe 
in  labour  premature  at  the  sixth  month.  With  rigidity  may  be 
associated  oedema  of  the  hypertrophied  cervix,  whereby  the 
obstruction  is  increased. 

In  rare  cases  failure  of  dilatation  may  depend,  not  upon  any 
widespread  induration,  but  on  primary  smallness  of  the  external 
OS,  associated  with  some  rigidity  of  its  edge.  Since  the  resistance 
of  the  rim  of  the  os  to  dilatation  is  inversely  proportioned  to  its 
diameter  (see  p.  217),  it  is  evident  that  a  very  minate  os  will  offer 
great  resistance  to  expansion  by  the  longitudinal  muscular  fibres, 
and  will  entirely  jDrevent  any  projection  of  the  bag  of  membranes 
into  it  to  form  a  dilator.  In  one  such  case,  after  labour  pains  had 
lasted  for  a  week,  I  found  the  os  with  difficulty  to  be  detected. 
First  a  small  catheter,  then  the  little  finger,  and  next  the  index  and 
middle  fingers  were  got  into  it  in  quick  succession.  Sj)ontaneous 
dilatation  then  went  on  rapidly,  and  labour  was  completed  within  a 
very  few  hours  ;  but  the  child  was  still-born,  apparently  from  the 
effect  of  the  prolonged  first-stage  uterine  contractions. 

Diagnosis. — When  the  os  has  a  thin,  hard,  undilatable  edge,  it 
may  be  expected  that  the  dilatation  stage  will  be  prolonged.  This 
condition  is  commonest  in  primiparee,  and  probably  depends  more 
upon  initial  rigidity  of  tissue  than  upon  spasm.  In  other  cases  the 
edge  of  the  os  is  found  rigid,  although  thick,  especially  in  parous 
women,  who  have  had  hyperplasia  of  the  cervix.  It  may  be  inferred 
with  probability  that  spasm  is  an  important  element  in  the  case 
when  the  pains  are  inefi'ective  in  producing  tension  of  the  bag  of 
membranes,  or  pressure  upon  the  os  of  the  presenting  part  after 

^  For  a  discussion  of  the  causation  of  this  elongation  with   hyperplasia,  see   the 
author's  "  Diseases  of  Women." 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.   637 


the  membranes  have  ruptured,  especially  if  they  are  at  the  same 
time  irregular  or  unusually  distressing.  Deficiency  in  the  natural 
lubricating  secretion,  which  is  regulated  by  nerve  influence,  supports 
the  same  conclusion.  Hyperplasia  of  the  cervix  in  parous  women 
may  be  revealed  by  its  irregularity,  and  may  be  associated  with  a 
history  of  uterine  symptoms  before  pregnancy. 

Treatment. — In  general,  treatment  has  to  be  decided  upon  with- 
out absolute  knowledge  how  much  of  the  resistance  is  due  to  spasm, 
and  how  much  to  organic  rigidity. 
For  moderate  rigidity  in  the  early 
stage,  with  the  membranes  unruptured, 
and  so  long  as  no  serious  constitu- 
tional disturbance  is  produced,  time 
and  patience  are  the  best  remedies,  as 
for  deficiency  of  the  pains.  Inter- 
ference by  any  manipulation  at  too 
early  a  stage  runs  the  risk  of  making 
matters  worse  by  increasing  the  irri- 
tation. The  plan  previously  mentioned 
(see  p.  626)  of  making  sure  that  the 
membranes  are  not  adherent  around 
the  OS,  may,  however,  be  carried  out. 
There  is  one  safe  treatment  which  may 
be  adopted  without  fear,  namely,  the 
use  at  intervals  of  the  vaginal  douche 
with  a  large  supply  of  hot  water, 
which  should  have  been  sterilised  by 
boiling,  at  a  temperature  of  105°  to 
110°  F.  This  is  advantageous  in 
stimulating  the  pains,  •  as  well  as  in 
relaxing  the  os.  For  the  latter 
purpose    a   hot   hip-bath,    or,    better, 

whole  bath  may  also  be  used,  but  is  often  not  so  conveniently 
available.  If  contractions  are  unduly  painful  chloral  should 
be  administered  as  already  described  (see  p.  315),  and  often  has 
the  effect  of  making  the  pains  more  regular  and  effective.  For 
an  extreme  degree  of  this  condition,  however,  especially  when 
the  membranes  have  ruptured  prematurely,  and  the  os  remains 
rigid,  notwithstanding  frequent  pains,  chloroform  is  far  more 
effective  than  chloral,  and  also  has  the  advantage  that  the  effect 
passes  oft'  more  quickly  when  the  desired  result  is  sufficiently 
attained. 


Fig.  318. — Improved  hydrostatic 
dilator  for  cervix  uteri. 
a  h,  tube  into  which  the  in- 
troducer is  passed,  closed 
at  the  upper  end  b. 
The  dotted  outline  shows  the 
shape  of  the  bag  when 
expanded.       For    intro- 
duction, the  corners  c  d 
are  folded  inwards. 


638  The  Practice  of   Midwifery. 

Artificial  Dilatation. — Artificial  dilatation  should  be  undertaken 
if  there  is  long  protraction  of  the  first  stage  after  rupture  of  the 
membranes,  and  even  before  the  rupture  of  the  membranes,  if  the 
general  condition  of  the  patient  calls  for  it,  or  if  there  is  evidence 
of  undue  retraction  of  the  uterus.  It  is  to  be  remembered,  however, 
that  in  the  first  stage,  when  pains  are  frequent,  the  pulse  is  often 
more  accelerated  without  serious  import  than  in  the  second  stage, 
when  intermissions  are  longer. 

Hydrostatic  Diltitors. — The  chief  means  of  artificial  dilatation,  in 
the  earlier  stage,  are  the  use  of  hydrostatic  dilators  and  manual 
dilatation.  Of  these  the  former  method  is  usually  to  be  preferred 
when  practicable,  since  it  imitates  more  closely  the  natural  mode 
of  dilatation  by  the  fluid  wedge  of  the  liquor  amnii. 

A  modified  hydrostatic  dilator,  much  easier  to  introduce  than  the 
original  form  of  Dr.  Barnes,  is  shown  in  Fig.  318,  p.  637.  The 
corners  are  doubled  inward  when  the  bag  is  in  the  undilated  state, 
so  that  the  upper  end  of  it  is  conical  and  slips  easily  through  the 
OS,  and  the  introducer  passes  through  the  centre  of  the  bag.  One 
of  the  thick  metallic  bougies,  used  for  dilatation  of  the  cervix  uteri, 
answers  best  as  an  introducer,  but  the  ordinary  uterine  sound  may 
be  used.  The  tube  attached  to  the  bag  should  have  a  stop-cock. 
The  bags  are  made  of  several  sizes,  to  be  used  at  difierent  stages  of 
dilatation.  For  sterilisation  the  bag  may  be  dipped  for  a  minute 
or  so  in  boiling  water,  and  then  immersed  in  an  efficient  antiseptic, 
as  formalin  53.  ad  Oj.,  or  iodide  of  mercury  1  in  500.  For  intro- 
duction of  the  bag  the  patient  may  be  placed  in  the  left  lateral 
position,  the  left  hand  or  half-hand  passed  into  the  vagina — if  the 
vagina  is  capacious  enough — and  one  or  two  fingers  placed  just 
within  the  posterior  margin  of  the  os.  The  bag  is  then  guided  up 
the  flexor  surface  of  the  fingers,  and  passed  up  between  the 
presenting  part  and  the  posterior  uterine  wall  till  it  is  nearly 
half-way  through  the  cervix. 

The  lower  end  of  the  tube  by  which  the  bag  is  filled  should  be 
so  adjusted  as  to  fit  on  to  the  nozzle  of  the  Higginson's  syringe. 
Before  any  bag  is  introduced  it  is  well  to  measure  by  trial  how 
many  syringefuls  of  water  it  will  hold  without  over-stretching  the 
india-rubber.  If  this  be  not  known,  the  bag  is  apt  to  be  over- 
stretched, and  possibly  may  burst,  letting  the  water  escape  into 
the  uterus.  As  soon  as  the  bag  is  in  place,  the  same  number  of 
syringefuls  of  warm  sterilised  water  is  to  be  pumped  in,  or  any- 
thing short  of  this  number  which  will  make  the  lower  part  of  the 
bag  sufiiciently  tense.  If  possible  the  lower  end  of  the  bag  should 
be  kept  well  backwards,  so  that  the  posterior  vaginal  wall  may 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    639 

support  it,  and  prevent  its  being  so  easily  squeezed  out  into  the 
vagina  by  the  uterine  action.  The  bag  when  in  place,  as  well  as 
being  a  mechanical  dilator  of  the  cervix,  is  a  powerful  stimulant  to 
expulsive  pains  when  these  are  deficient.  The  position  of  the  bag 
should  be  noted  from  time  to  time,  and  it  should  not  generally  be 
left  in  place  more  than  about  an  hour  without  removal,  to  note 
the  progress  made.     If  the  bag  is  expelled  by  the  uterus  wholly 


Fig.  319. — Champetier  de  Ribes'  hydrostatic  dilator,  with  forceps  for  introduction. 


into  the  vagina,  it  will  frequently  be  found  that  it  has  already  done 
its  work,  and  that  a  larger  size  can  be  introduced.  The  only 
drawback  to  the  use  of  the  hydrostatic  dilator  is  that,  by  pushing 
up  the  head,  especially  after  escape  of  the  liquor  amnii,  it  may 
l)0ssibly  promote  displacement  of  the  head  from  the  brim,  and 
descent  of  the  hand,  arm,  or  shoulder.  On  the  removal  of  any 
bag,  therefore,  it  should  be  noted  whether  the  presentation  remains 
undisturbed.     If  the  head  has  been  pushed  to  one  side,  it  can 


640  The   Practice  of   Midwifery. 

generally  be  replaced  easily  by  external  or  bimanual  manipulation 
(see  Chapter  XXXIV.). 

Another  form  of  hydrostatic  dilator  has  been  introduced  by 
Champetier  de  Eibes,  Fig.  319,  p.  639.  This  embodies  two  prin- 
ciples :  (1)  the  bag  is  made  of  inelastic  material ;  (2)  it  is  about 
the  size  of  a  foetal  head,  and  therefore,  when  fully  distended,  cannot 
be  expelled  without  dilating  the  cervix  sufficiently.  This  can  be 
introduced  if  the  index  and  middle  fingers  can  be  passed  as  far  as 
their  first  articulation.  After  sterilisation  by  boiling,  all  air  is  to 
be  expelled  from  the  bag.  It  is  then  folded  and  placed  between  the 
blades  of  the  forceps,  the  distal  end  of  the  bag  projecting  some 
centimetres  beyond  the  end  of  the  forceps,  and  all  freely  lubricated 
with  lanocyllin,  or  glycerine  containing  perchloride  of  mercury 
1  in  1,000.  The  tips  of  two  fingers  being  inserted  within  the 
cervix,  the  bag  is  passed  in  between  them.  First  one  finger  and 
then  the  other  is  withdrawn  and  the  bag  is  passed  on  till  it 
penetrates  10 — 12  centimetres  (4 — 4f  inches)  within  the  internal 
OS.  The  bag  is  then  filled  by  an  assistant  with  1  -per  cent,  carbolic 
solution,  while  the  operator  with  one  hand  holds  the  forceps,  with 
the  other  feels  what  is  going  on  at  the  level  of  the  internal  os. 
Meanwhile  the  forceps  are  opened,  but  not  removed  until  the  bag 
is  dilated  to  such  a  size  as  will  not  admit  of  its  descent.  A  syringe 
of  about  6  ounces  capacity  is  used  for  filling  the  bag.  According  to 
the  inventor,  to  fill  the  bag  completely,  and  give  it  a  circumference 
of  33  cm.  (13  inches),  640  grammes  (22'4  ounces)  must  be  injected ; 
if  540  grammes  (18'9  ounces)  be  injected,  the  circumference  will  be 
27  cm.  (10'6  inches) ;  if  440  grammes  (15"4  ounces)  be  injected,  the 
circumference  will  be  22  cm.  (8'7  inches).  When  the  bag  is  filled 
the  operator  ties  a  tape  round  the  tube,  so  as  not  to  be  entirely 
dependent  upon  the  stop-cock.  An  antiseptic  vaginal  douche  is 
then  given,  and  repeated  frequently  during  the  course  of  labour. 

If  there  is  urgent  need  to  accelerate  delivery,  as  in  cases  of 
eclampsia  or  haemorrhage,  a  weight  of  2  lb.  may  be  tied  to  the 
neck  of  the  bag  and  hung  on  a  pulley  over  the  edge  of  the  bed. 

The  advantages  which  this  bag  presents  over  any  variety  of 
Barnes's  bags  are  that  it  does  not  lose  its  shape,  as  it  is  inelastic, 
produces  complete  dilatation  of  the  cervix,  does  not  tend  to  slip 
out,  and  is  easy  to  introduce.  Its  main  disadvantage  is  its  tendency 
to  displace  the  presenting  part,  and  in  some  cases  its  large  size  may 
make  it  difficult  to  find  room  for  it  within  the  uterus.  This 
difficulty  may  in  some  cases  be  overcome  by  rupturing  the 
membranes.  I  have  used  similar  bags  made  of  a  smaller  size,  which 
allow  introduction  through  a  smaller  os  uteri. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    641 

Manual  Dilatation. — There  are  certain  cases  in  which  the  hydro- 
static dilators  are  inapplicable,  namely,  when,  after  rupture  of 
the  membranes,  the  head  is  pressed  so  firmly  down  upon  the 
OS  that  the  bag  cannot  be  introduced  without  too  great  force,  and 
also  when  the  uterus  is  acting  so  powerfully  that  the  bag  is 
squeezed  out  immediately  after  introduction.  It  is  chiefly  in  the 
latter  stages  of  dilatation  that  these  difficulties  are  likely  to  arise. 
Under  these  circumstances,  or  when  hydrostatic  dilators  are  not 
at  hand,  manual  dilatation  is  very  efficacious,  and  it  is  even  pre- 
ferred by  some  authorities  under  all  conditions,  because  the  dilator 
itself  is  sentient,  and  can  estimate  the  degree  of  tension  exercised. 
The  left  hand  may  be  used,  the  patient  being  in  the  left  lateral 
position,  or  either  hand  when  she  lies  on  the  back.  The  left  hand 
is  introduced  into  the  vagina,  and  two  fingers  are  hooked  into  the 
OS,  drawing  it  somewliat  forward.  The  tips  of  the  fingers  are  then 
gradually  introduced  in  the  form  of  a  cone,  until  four  fingers  can 
be  passed  in  side  by  side.  When  the  os  has  reached  this  size, 
dilatation  can  still  be  carried  on  by  separating  the  fingers,  but  this 
soon  fatigues  the  muscles.  Dilatation  can  be  carried  on  longer 
and  more  steadily  if  the  whole  hand  is  now  introduced  into  the 
vagina,  and  the  wedge  which  it  forms  enlarged  by  addition  of  the 
thumb,  until  the  os  will  admit  the  full  breadth  of  the  hand.  For 
this  manipulation,  chloroform  is  not  generally  indispensable,  but 
it  may  be  used  with  advantage  if  the  resistance  is  probably  due  to 
spasm  of  the  os,  or  if  the  patient  is  over-sensitive  to  pain.  When 
the  OS  is  large  enough  to  admit  the  width  of  the  hand,  the  pre- 
senting part  will  generally  be  able  to  enter  it  deeply  and  complete 
the  dilatation  through  the  natural  powers.  Even  in  this  latest 
stage,  however,  digital  manipulation  may  assist,  if  the  anterior  lip 
of  the  cervix  is  driven  down  deeply  in  the  pelvis,  in  front  of  the 
head.  During  each  pain  the  fingers  may  be  placed  on  the  margin 
of  the  OS  nearest  to  the  posterior  fontanelle,  so  as  to  retract  it 
until  it  slips  over  the  occiput,  which  is  naturally  the  part  of  the 
head  to  emerge  first. 

Instrumental  Dilators. — A  very  powerful  and  efficient  four- 
bladed  dilator  has  been  introduced  by  Bossi  (Fig.  321).  When 
the  OS  is  quite  small,  or  the  cervical  canal  unobliterated,  the 
blades  are  used  without  the  sheaths.  If  only  the  external  os  has 
to  be  dealt  with,  and  some  dilatation  is  already  attained,  the 
sheaths  tend  to  prevent  the  ends  of  the  blades  slipping  out.  In 
urgent  cases,  dilatation  may  be  effected  within  half  an  hour.  But 
it  is  advisable  for  the  operator  to  allow  ample  time,  watching  the 
expansion   attained,    as  shown  by  the   indicator,  and  testing  the 

M.  41 


642 


The   Practice  of   Midwifery. 


tension  of  the  edge  of  the  os  by  the  finger.  Otherwise  the  dilator 
may  cause  a  commencement  of  laceration,  which  is  increased  by  the 
advancing  head.  On  an  average,  at  least  three  minutes  should  be 
allowed  for  each  centimetre  as  registered  by  the  indicator,  and  the 
operator  should  keep  his  watch  before  him.     For  the  earlier  stages 


# 


Fig.  320.— Frommer's  dilator. 


Fig.  321.— Bossi"s  dilator. 


more  time  should  be  allowed,  since  the  addition  of  a  centimetre 
then  means  a  greater  proportionate  increase. 

In  a  modified  form  of  dilator,  that  of  Frommer,  the  blades  are 
eight  instead  of  four.  This  makes  the  tension  on  the  edge  of  the 
OS  somewhat  more  uniform.  The  disadvantages  are  that  there  is 
no  option  of  using  sheaths  for  the  blades,  and  that,  at  the  earlier 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    643 

stages  of  dilatation,  the  finger  cannot  be  passed  between  the  blades 
to  test  the  tension  of  the  edge  of  the  os. 

Considerable  care  should  be  exercised  in  the  use  of  these  dilators, 
as  there  is  great  danger  if  the  dilatation  is  carried  out  rapidly  of 
causing  severe  tears  of  the  cervix.  As  a  general  rule  their  use 
should  be  restricted  to  cases  where  the  internal  os  has  already 
undergone  some  degree  of  dilatation,  and  the  cervical  canal  is 
partly  taken  up.^ 

ApiMcation  oj  Forcejjs. — After  dilatation  has  been  carried  as  far 
as  is  possible  by  hydrostatic  dilators  or  manual  dilatation,  the 
means  most  available  for  hastening  delivery,  if  necessary,  especially 
in  the  absence  of  Bossi's  or  Frommer's  dilator,  is  the  aj)plication 
of  forceps.  This  means,  however,  should  never  be  adopted  merely 
to  shorten  the  patient's  suffering,  or  save  the  practitioner's  time, 
but  only  when  the  rising  pulse  or  other  general  symptoms  due  to 
protracted  labour  indicate  the  necessity  for  interference.  Even  then 
it  is  well  first  to  employ  full  manual  dilatation  with  the  aid  of 
chloroform,  and  then  wait  a  short  time  to  see  what  nature  will  effect. 
It  will  then  be  found  to  be  only  very  rarely  that  the  use  of  forceps 
is  called  for  on  account  of  the  resistance  of  the  os  alone.  The  case 
has  carefully  to  be  distinguished  in  which,  on  account  of  dispro- 
portion between  the  fcetus  and  the  pelvis,  the  head  is  prevented 
from  fully  entering  the  os  as  a  dilator,  though  the  os  itself  is 
dilatable.  A  comparatively  early  application  of  forceps  is  then 
desirable. 

The  contrary  practice,  namely,  the  comparatively  frequent  use 
of  forceps  before  full  dilatation  of  the  os,  has  been  recommended 
by  some  authorities,  especially  by  Dr.  G.  Johnston,  as  master  of 
the  Eotunda  Hospital,  Dublin.  Dr.  Johnston  invented  a  special 
form  of  forceps  with  narrow  blades,  in  order  to  be  able  to  pass 
them  through  a  comparatively  undilated  os.  In  his  last  four  years 
of  office,  with  a  total  forceps-rate  of  116*4  per  1,000,  he  applied 
forceps  in  more  than  one-fourth  of  the  cases  (or  at  the  rate  of  more 
than  29  per  1,000,  a  rate  about  six  times  as  great  as  the  total 
forceps-rate  in  the  Guy's  Hospital  Lying-in  Charity,  1863 — 1875) 
before  fall  dilatation  of  the  os.  Of  these,  the  head  was  at  or  above 
the  brim  in  considerably  more  than  half,  and,  in  more  than  a  third, 
the  OS  was  less  than  two-fifths  dilated.  As  already  mentioned  (see 
p.  632),  Dr.  Johnston's  results  do  not  show  any  material  gain  in 
the  rate  of  still-births,  and  they  certainly  do  not  show  that  such  a 
practice  is  safe  for  the  mothers,  even  in  such  skilled  hands  as  his. 
The  maternal  death-rate  (1871—1875)  was  19-3  per  1,000,  a  very 

1  Blacker,  Trans.  Med.  Soc.  London,  190(5,  Vol.  XXIX.,  p.  170. 

41—2 


644  The   Practice  of   Midwifery. 

high  one.  This  may,  indeed,  have  been  due  to  the  septic  risks  in 
a  lying-in  hospital,  before  the  introduction  of  the  latest  improve- 
ments in  antiseptic  midwifery.  But  in  88  cases,  during  the  three 
years,  1872 — 1874,  in  which  forceps  were  applied  before  full 
dilatation  of  the  os,  simply  on  account  of  premature  rupture  of 
the  membranes — excluding  all  cases  of  complication,  such  as 
eclampsia,  haemorrhage,  or  prolapse  of  funis,  and  excluding  also 
cases  of  disproportion- — there  were  four  deaths,  i.e.,  a  death-rate 
of  46"6  per  1,000.  It  would  hardly  have  been  anticipated  that 
the  increased  risk  from  premature  rupture  of  the  membranes, 
without  any  other  difficulty  or  complication,  would  have  led 
to  so  great  a  mortality,  if  the  cases  had  been  left  to  nature, 
or  treated  merely  by  other  modes  of  dilatation.  Again,  taking 
into  consideration  the  whole  number  of  forceps  cases,  the  forceps- 
rate,  which  under  Dr.  Shekleton  (1847—1854)  was  16-5  per  1,000, 
rose  under  Dr.  Johnston  (1871—1875)  to  116'4  per  1,000.  But 
the  mortality  after  use  of  forceps  per  1,000  deliveries  rose  from 
0*43  to  6'2,  or  in  more  than  double  the  proportion.  Again,  the 
deaths  per  1,000  in  the  forceps  cases  themselves  were  under  Dr. 
Johnston  (1871 — 1875)  54*4,  while  under  Dr.  Shekleton,  although 
the  use  of  forceps  was  reserved  for  much  more  extreme  cases,  they 
were  only  35*7. 

The  conclusion  therefore  remains  undisturbed  that  forceps  should 
never  be  applied  until  the  os  allows  the  easy  application  of  the 
ordinary  form  of  instrument.  The  os  can  always  be  expanded  up 
to  this  point  by  manual  dilatation,  or  by  Bossi's  dilator,  which 
has  to  a  great  extent  obviated  the  need  for  using  forceps  as  a 
dilator  of  the  cervix.  Whenever  forceps  are  applied  when  the  head 
is  still  within  the  uterus,  and  a  rim  of  the  cervix  remains  over  the 
head,  whether  the  cause  of  delay  lies  in  the  cervix  or  in  any  other 
condition,  extraction  should  be  carried  out  with  extreme  care  and 
slowness,  in  order  to  give  the  cervix  time  to  yield,  and  avoid  as  far 
as  possible  the  risk  of  laceration. 

Incision  of  the  Cervix. — It  is  not  desirable  to  incise  the  cervix  so 
long  as  there  is  hope  of  overcoming  the  difficulty  by  dilatation, 
since  incisions,  like  spontaneous  lacerations,  by  laying  open  the 
cellular  tissues,  expose  to  the  risk  of  septic  absorption,  and  the 
incisions  are  apt  to  be  extended  by  laceration.  If,  however,  other 
means  fail,  and  the  condition  of  the  patient  demands  interference, 
the  edge  of  the  cervix  may  be  incised  at  three  or  four  places,  to 
not  more  than  half  an  inch  in  depth.  The  incisions  may  be  made 
with  Kuchenmeister's  scissors  (designed  for  incising  the  unimpreg- 
nated  cervix),  or  with  ordinary  scissors,  or  with  a  blunt-pointed 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    645 

bistoury,  having  only  about  half  an  inch  of  cutting  edge  exposed 
and  guided  up  to  the  resisting  edge  by  the  finger.  The  method  of 
incision  is  most  applicable  when  the  difficulty  is  due  to  organic 
induration  or  cicatricial  tissue,  not  extending  far  beyond  the  edge 
of  the  cervix. 

Version  or  Craniotomy . — It  will  only  be  in  extremely  rare  cases 
that  the  resistance  of  the  os  leads  to  such  grave  risks  to  the  mother 
as  to  justify  sacrifice  of  the  child,  or  even  the  increased  danger 
to  it  involved  by  version.  When  the  mother  is  in  great  danger 
from  other  causes,  as  from  eclampsia,  and  the  os  will  not  yield,  or 
when  there  are  very  strong  grounds  for  believing  the  child  to  be 
already  dead,  either  version  or  craniotomy,  according  to  the 
condition  of  the  uterus,  may  be  called  for. 

Vaginal  or  Abdominal  C cesarean  Section. — In  extreme  cases,  where 
incisions  of  the  cervix  are  required,  it  will  often  be  better  practice 
to  carry  out  at  once  vaginal  Csesarean  section  and  delivery  of  the 
child.  At  any  rate,  in  the  early  months  of  pregnancy  this  is 
probably  the  best  method  of  dealing  with  very  extreme  degrees  of 
rigidity  of  the  cervix,  and  in  the  later  months  it  may  in  a  few 
instances  be  necessary  to  perform  abdominal  Caesarean  section  for 
rigidity  of  the  cervix,  especially  that  due  to  cicatricial  contraction. 

Atresia  of  the  Cervix. — The  cervix  must  of  course  have  been 
permeable  for  pregnancy  to  occur.  In  some  cases,  however,  no 
opening  has  been  discoverable  at  the  onset  of  labour.  Adhesion  of 
inflammatory  granulations  may  have  been  formed  after  conception, 
sometimes  as  a  result  of  the  too  vigorous  application  of  caustics  in 
the  treatment  of  cervical  inflammation,  or  of  attempts  to  procure 
abortion.  Care  must  be  taken  to  reach  every  part  of  the  vagina 
and  cervix,  before  it  is  assumed  that  there  is  no  opening,  lest  the 
case  be  really  one  of  malposition  of  the  os. 

Treatment. — When  labour  pains  have  commenced,  a  puncture 
or  incision  must  be  made  at  the  site  of  the  os,  or  at  the  centre  of 
the  lower  segment  of  the  uterus,  if  the  site  cannot  be  discovered. 
Dilatation  is  then  to  be  carried  on  by  metallic  bougies,  dressing 
forceps,  fingers,  hydrostatic  bags,  or  other  convenient  means,  until 
there  is  space  for  the  bag  of  membranes  to  bulge  into  the  opening 
and  continue  the  dilatation. 

Malposition  of  the  Os. — It  has  already  been  mentioned  that 
the  result  of  retroversion  in  the  early  months  is  supposed  to  be,  in 
some  cases,  the  displacement  of  the  os  forward  at  full  term,  so  that 
it   lies  out  of  reach,   or  nearly  so,  behind,  and  even    above,  the 


646  The  Practice  of   Midwifery. 

sj'mphysis  pubis  (see  p.  502).  Other  authorities  attribute  the  same 
condition  to  a  sacciform  development  of  the  posterior  uterine  wall. 
Similarly  the  os  may  be  displaced  backward,  opposite  the  promon- 
tory of  the  sacrum.  Displacement  of  the  os  backward  may  also 
result  from  a  previous  vaginal  hysteropexy.  "Whatever  the  cause 
be  of  this  condition,  the  result  is  the  same.  The  os  is  unfavourably 
placed  for  dilatation  by  the  muscular  j&bres,  or  for  projection  of  the 
bag  of  membranes  into  it.  The  presenting  part  cannot  enter  it  at 
all,  for  it  lies  in  the  cul-de-sac  which  forms  the  lower  extremity 
of  the  uterus.  Especially  if  the  liquor  amnii  has  escaped  does 
the  mechanism  of  dilatation  fail  altogether,  and  labour  may  be 
indefinitely  prolonged. 

Treatment. — If  a  hydrostatic  dilator  can  be  introduced  into 
the  OS,  this  means  may  be  emj^loyed.  As  the  os  becomes  dilated, 
it  wmII  tend  to  approximate  toward  the  axis  of  the  uterus.  In 
general  the  best  plan  is  to  hook  the  finger  into  the  lower  margin  of 
the  displaced  os,  and  to  stretch  it  by  drawing  it  toward  the  central 
axis  of  the  pelvis.  Chloroform  should  be  administered,  if  necessary, 
and  a  hydrostatic  dilator  may  be  used  at  a  later  stage.  If  the 
head  lies  in  the  lower  cul-de-sac,  and  cannot  be  got  to  enter  the 
OS  when  fair  dilatation  has  been  attained,  delivery  by  version  may 
be  necessary.  Cesarean  section  has  been  performed  for  displace- 
ment of  the  OS  uteri.  But  it  is  probable  that  patience,  with  more 
gradual  treatment,  as  above  described,  involves  a  less  risk  to  the 
patient,  and  will  always  ensure  a  favourable  result. 

Cicatrices  and  Atresia  of  the  Vagina  and  Vulva. — 
Cicatrices  of  the  vagina  are  most  frequently  the  result  of  sloughing 
after  protracted  labour  in  former  pregnancies.  Some  of  the  most 
severe  forms  aiise  in  conjunction  with  vesico-vaginal  or  recto- 
vaginal fistulffi.  Cicatrices  may  also  result  from  syphilitic  deposits, 
or  from  local  injuries  or  operations  apart  from  parturition. 
Sometimes  there  is  an  almost  complete  atresia  from  a  congenital 
transverse  vaginal  septum  above  the  level  of  the  hymen,  or  the 
hymen  itself  may  have  a  small  orifice,  and  may  have  been  so 
tough  as  not  to  yield  in  coitus.  Cicatrices  which  involve  deeply 
the  surrounding  cellular  tissue  are  serious  in  their  effects.  They 
may  be  so  resisting  that  the  fcetus  cannot  pass  without  such 
lacerations  as  to  lay  open  cellular  tissue  extensively,  and  involve 
the  risk  of  subsequent  sejDtic  absorption.  Similarly,  existing 
fistulse  may  be  increased  in  extent. 

Treatment. — If  there  is  any  congenital  septum,  the  aperture 
should  be  dilated  by  bougies,  tents,  or  hydrostatic  dilators.       Or, 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    647 

if  thin,  the  septum  may  be  incised.  In  the  case  of  cicatrices,  fair 
time  should  be  allowed  to  see  the  effect  of  the  natural  forces,  and 
the  softening  associated  with  parturition.  If  the  cicatrices  form  an 
almost  complete  vaginal  atresia,  the  dilatation  may  be  commenced 
with  laminaria  tents.  If  necessary,  the  most  resisting  transverse 
bands  should  be  incised  with  scissors  or  a  blunt-pointed  bistoury. 
The  tissues  may  then  be  further  stretched  with  the  fingers,  or  the 
head  allowed  to  continue  the  stretching.  In  some  cases,  extraction 
by  forceps  or  after  craniotomy  may  be  required,  cicatricial  bands 
being  divided  further,  as  may  be  necessary,  during  the  extraction. 
It  will  be  better  treatment  to  perform  Caesarean  section^  if  the 
cicatricial  tissue  fills  up  the  pelvis,  or  if  its  incision  is  likely  to 
injure  the  bladder  or  the  rectum.  Sj)encer^  has  recorded  a  case  of 
this  kind  in  which  he  performed  a  Porro-Ceesarean  section  for  com- 
plete atresia  of  the  vagina  following  on  supra-vaginal  amputation  of 
the  cervix  for  cancer. 

EiGiDiTY  OF  THE  Perineum. — Piigidity  of  the  vaginal  outlet  and 
perineum  is  a  very  frequent  cause  of  delay  in  the  latter  part  of 
the  second  stage  of  labour  in  primiparae,  especially  if  the  uterus  is 
then  becoming  fatigued.  Both  the  difficulty  and  the  risk  of  rupture 
are  increased  if  the  pubic  arch  is  narrower  than  usual,  so  that  the 
head  is  thrown  more  backward  upon  the  perineum.  Difficulty 
may  arise  even  in  subsequent  labours,  if  the  perineum  has  been 
repaired  after  rupture  on  a  previous  occasion,  if  cicatricial  tissue 
has  remained  after  previous  rupture,  or  if  the  child  is  larger  than 
former  children  have  been. 

Treatment. — Digital  manij)ulations  are  often  of  value  in  aiding 
the  dilatation  of  the  perineum  and  avoiding  rupture.  While  the 
head  is  retarded  during  a  pain,  in  the  mode  already  described 
(p.  303),  if  there  appears  to  be  danger  of  rupture,  the  index  and 
middle  fingers  may  be  used  to  retract  the  perineum  and  gradually 
stretch  it  in  the  intervals  of  pains.  This  can  be  carried  out  more 
effectually  if  chloroform  is  being  administered  during  the  labour. 
Hot  fomentations,  frequently  renewed,  may  also  be  used  when  the 
head  begins  to  distend  the  outlet.  Within  moderate  limits,  delay 
at  this  stage  is  conservative,  giving  the  structures  time  to  stretch 
under  the  influence  of  successive  pains,  and  it  is  often  desirable, 
while  observing  the  tension  placed  upon  the  perineum,  rather  to 
delay  the  advance  of  the  head  than  to  hasten  it.  If  delay  is  too 
great,  or  constitutional  symptoms  are  arising,  delivery  must  be 
effected  by  forceps.     Though  it  is  probable  that,  in  actual  practice, 

1  See  a  case  by  the  author,  Trans.  Obst.  Soc.  London,  1876,  Vol.  XVIII.,  p.  152. 

2  Spencer,  Trans.  Obst.  Soc.  London,  1896,  Vol.  XXXVUI.,  p.  413. 


648  The  Practice  of   Midwifery. 

perineal  rupture  is  more  frequently  caused  than  avoided  by  the 
use  of  forceps,  yet  this  will  not  be  the  case  if  forceps  are  not 
applied  prematurely,  and  the  extraction  is  made  with  sufficient 
patience  and  slowness.  For  the  force  is  not,  like  the  natural 
expulsive  force,  inclined  backwards  in  reference  to  the  axis  of  the 
outlet,  so  as  to  press  needlessly  upon  the  perineum,  and  it  may 
be  made  more  gradual  than  the  effect  of  the  pains  of  the  final 
stage  of  delivery.  When  there  appears  to  be  great  risk  of  rupture, 
the  extraction  should  be  made  by  continuous  steady  traction  in 
the  interval  of  pains,  the  finger  being  kept  all  the  while  upon  the 
edge  of  the  perineum,  to  estimate  its  tension.  Unless  the  patient's 
self-control  can  be  thoroughly  relied  upon,  it  is  well  to  keep  her 
pretty  fully  under  the  influence  of  chloroform,  that  she  may  not 
make  a  sudden  movement.  The  plan  recommended  by  some, 
namely,  to  jDerform  cpisciotomy,  that  is,  to  make  two  lateral  inci- 
sions in  the  edge  of  the  perineum,  in  order  to  avoid  a  central 
laceration,  is  not  generally  desirable.  For  it  is  never  possible  to  be 
certain  when,  and  to  what  extent,  a  laceration  is  inevitable.  And 
the  clean-cut  laceration  itself  will  almost  invariably  unite,  if 
properly  closed  by  sutures.  In  rare  cases  only,  in  which  a  lacera- 
tion through  the  sphincter  ani  appears  to  be  otherwise  inevitable, 
this  operation  is  advantageous. 

Cancer  of  the  Cervix  Uteri  and  Pelvis. — About  once  in  2,000 
cases  of  pregnancy^  conception  occurs  notwithstanding  the  existence 
of  cancer  of  the  cervix  uteri  in  its  earlier  stage.  When  this  is  the 
case,  the  stimulus  of  pregnancy  generally,  but  not  in  all  cases, 
causes  a  rapid  growth  of  the  cancer,  so  that  when  full  term  is 
reached,  the  disease  may  have  reached  to  a  very  formidable  extent, 
even  involving  the  whole  circuit  of  the  cervix,  and  extensively 
infiltrating  the  cellular  tissue  around.  In  other  cases  cancer  of 
the  vagina,  or  cancer  commencing  elsewhere  in  the  pelvis,  as  from 
the  rectum,  forms  such  a  mass  in  the  cellular  tissue  that  the 
passage  of  the  foetus,  even  after  embryotomy,  becomes  difficult  or 
impossible. 

Results. — In  some  cases,  relief  is  brought  by  nature  through 
the  occurrence  of  spontaneous  abortion  or  premature  labour.  If 
pregnancy  goes  on  to  the  later  months,  the  complication  is  very 
formidable.  The  difficulty  in  parturition  depends  not  only  upon 
the  extent  of  the  growth,  but  still  more  upon  its  hardness.  A 
certain  amount  of  the  softening  of  parturition  may  take  place  even 
in  the  diseased  cervix  :  spontaneous  lacerations  may  give  increased 

1  Sarwey,  Veil,  Handbuch  der  Gynakologie,  1899,  Vol.  III.,  Part  2,  p.  489. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    649 

space,  and  sometimes  even  unassisted  delivery  takes  place  with  less 
difficulty  than  had  been  anticipated.  If  some  part  of  the  cervix 
remains  free,  it  is  generally  possible  to  get  sufficient  dilatation  to 
deliver  the  fcetus  by  some  means,  and,  even  when  the  whole  circuit 
is  involved,  this  sometimes  proves  possible,  provided  that  there  is 
not  too  much  infiltration  of  the  cellular  tissue  around  with  hard 
growth,  and  that  the  growth  itself  does  not  form  too  large  a  mass 
to  allow  the  foetus  to  pass. 

The  danger,  however,  is  by  no  means  over  with  delivery. 
Decomposition  and  inflammation  or  sloughing  of  the  bruised 
cancerous  tissue  is  apt  to  follow,  and  the  most  frequent  cause  of 
death  is  septicaemia  set  up  in  this  manner.  When  the  whole  circuit 
of  the  cervix  is  so  involved  in  the  disease  that  no  commencement 
of  dilatation  can  occur  spontaneously,  the  uterus  sometimes  passes 
into  the  state  of  continuous  action  without  the  occurrence  of  any 
distinct  rhythmical  pains.  The  pulse  rises  therewith,  and  the 
general  condition  becomes  serious.  In  other  very  rare  cases, 
when  the  uterus  has  remained  quiescent,  the  fcetus  has  died,  and 
been  retained  within  the  uterus  beyond  full  term,  thus  constituting 
one  form  of  the  so-called  "  missed  labour  "  (see  p.  549).  Some- 
times before  any  onset  of  labour  a  condition  of  severe  constitutional 
irritation,  with  elevation  of  pulse  and  temperature,  and  dry  tongue, 
supervenes.  This  appears  to  be  due  to  septic  absorption  from  the 
cancerous  discharge,  and  to  be  liable  to  be  induced  by  any 
interference  with  the  cervix,  even  by  repeated  digital  examination. 
Some  patients  die  undelivered  from  the  effects  of  the  disease,  or 
after  an  abortive  attempt  at  labour,  or  after  fruitless  attempts  to 
deliver  them.  In  others  rupture  of  the  uterus  occurs  (11  out  of 
180,  Herman). 

Prognosis. — Excluding  cases  in  which  abortion  occurs,  the 
mortality  within  the  puerperal  period  in  recorded  cases  is  about 
43'3  per  cent.-"^  Even  in  cases  in  which  labour  terminates  naturally 
without  assistance,  it  is  over  30  per  cent.  The  mortality  of  the 
children  is  also  very  considerable,  being  about  38  per  cent.  This 
is  not  solely  due  to  the  effects  of  protracted  labour,  but  partly  to 
the  tendency  of  the  disease  to  bring  on  labour  prematurely,  and  to 
the  feeble  vitality  of  the  children,  or  their  death  in  utero  before 
labour  ;  also  the  consequences  of  the  disease. 

Treatment. — This  is  a  case  in  which  the  interests  of  the  mother 
have  to  be  balanced  against  those  of  the  child.     Accordingly  some 

1  Sarwey,  loc.  cit. 


650 


The  Practice  of   Midwifery. 


authorities,  considering  that  the  mother  must  die  before  very  long 
in  any  case,  have  considered  that  special  regard  ought  to  be  paid  to 
the  life  of  the  child.  In  this  country  it  will  be  generally  considered 
that  the  physician  has  not  the  right  to  sacrifice  even  a  probable 
temporary  prolongation  of  the  mother's  life  for  the  sake  of  the 


Fig.  322. — Uterus  removed  by  Wertheim's  operation  after  the  child  had  been 
delivered  by  Cesarean  section  in  a  case  of  cancer  of  the  cervix  obstruct- 
ing delivery.  The  patient  had  been  thirty-six  hours  in  labour,  and 
attempts  to  deliver  with  forceps  had  failed.  The  incision  in  the  uterus  is 
represented  as  sewn  up  to  show  the  method  of  suturing  in  Osesarean 
section.^ 


unborn  infant,  especially  since  the  preservation  of  a  motherless 
infant  is  not  always  an  unmixed  advantage.  It  is  only  when  the 
chances  of  the  mother  are  very  evenly  balanced  in  the  choice 
between  two  modes  of  treatment,  as  between  craniotomy  and 
Caesarean  section,  when  delivery  is  likely  to  be  very  difficult,  that 

1  Univ.    Coll.   Hosp.  Med.    School  Mus.      Gray,    quoted   by   Lockyer,  Brit.    Med. 
Journ.,  October  9,  1909,  p.  104i. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    651 

the  consideration  of  the  child's  life  may  justly  have  some  weight, 
especially  if  the  parents  are  anxious  for  its  preservation. 

As  a  general  rule  the  decision  is  one  which  must  be  made  by  the 
woman  or  her  husband  when  all  the  facts  of  the  case  have  been 
laid  before  them. 

In  discussing  the  treatment  of  this  condition  it  will  be  best  to 
consider  first  those  cases  in  which  the  cancer  is  operable  in  the 
usual  sense  of  the  term,  that  is  to  say,  there  is  a  reasonable  prospect 
by  operation  of  complete  extirpation  of  the  growth.  In  such  cases 
there  can  be  no  question  that  the  patient  should  be  operated  upon 
without  delay,  and  that  the  life  of  the  child  should  not  be  con- 
sidered. The  only  exception  to  this  rule  would  be  that  of  a  patient 
in  the  later  months  of  pregnancy,  who,  for  the  sake  of  obtaining 
possibly  a  living  child,  elected  to  run  the  risk  of  waiting  a  few 
weeks  before  being  operated  upon. 

In  the  early  months  of  pregnancy  there  is  a  choice  between  the 
induction  of  abortion  with  subsequent  extirpation  of  the  uterus  or 
immediate  hysterectomy  without  preliminary  emptying  of  the 
uterus. 

The  period  immediately  following  an  abortion,  like  the  puerperal 
period,  is  an  unfavourable  time  for  operations  ;  hence  the  former 
alternative  may  involve  a  delay  of  two  or  three  weeks  at  least  in 
the  removal  of  the  cancer. 

Undoubtedly  the  best  operation  in  the  early  months  of  pregnancy 
is  complete  extirpation  of  the  whole  uterus  by  the  vagina  or  by  the 
abdomen. 

In  the  later  months  the  abdominal  method  should  always  be 
chosen  for  hysterectomy.  The  modern  success  of  total  abdominal 
hysterectomy^  in  the  case  of  cancer  of  the  cervix  or  body  of  the 
uterus  justifies  this  operation  in  preference  to  vaginal  hysterectomy 
following  the  induction  of  abortion,  even  though  the  disease  may 
have  reached  the  vagina,  provided  it  has  not  spread  so  far  into  the 
broad  ligaments  as  to  prevent  the  whole  of  it  being  removed. 
Abdominal  section  is  performed,  and,,  if  the  child  is  viable,  it  is  first 
removed  by  Csesarean  section.  The  details  of  the  operation  are 
similar  to  that  of  panhysterectomy  following  Csesarean  section  at 
term,  and  are  described  in  Chapter  XXXVI. 

In  the  present  case  it  is  necessary  to  divide  the  vaginal  walls  as 
low  down  as  possible  so  as  to  give  a  wide  margin  of  healthy  tissue.^ 
Wertheim's  method  of  performing  the  operation  should  be  followed 

1  For  statistics  of  recorded  cases,  see  Herman,  "  The  Treatment  of  Pregnancy  com- 
plicated by  Cancerous  Disease  of  ihe  Genital  Canal,"  Obstet.  Trans.,  Vol.  XX.,  1878, 
p.  191.      Vide  also  Sarwey,  loc.  cit. 

'^  Wertheim,  Brit.  Med.  Journ.,  September  23,  1905,  p.  689. 


652  The  Practice  of   Midwifery. 

so  as  to  avoid  the  risk  of  infection  and  of  implantation  of  cancer 
cells  on  the  cut  surfaces.  An  alternative  is  to  perform  Diihrssen's 
vaginal  Caesarean  section  (see  Chapter  XXXVL),  and  then  remove 
the  uterus  by  vaginal  hysterectomy.  The  abdominal  operation 
allows  search  to  be  made  for  cancerous  glands,  and  a  more  free 
removal  of  the  broad  ligaments.  The  vaginal  operation  causes 
less  shock. 

In  inoperable  cases,  if  it  is  decided  not  to  consider  the  life  of  the 
child,  abortion  may  be  induced  in  the  early  months,  if  the  patient 
comes  then  under  observation,  and  the  disease  is  too  advanced  for 
extirpation.  The  reason  for  this  is  not  only  that  the  risks  after 
abortion  are  much  less  than  after  labour  in  the  later  months,  but 
that  the  possible  stimulus  of  pregnancy  to  the  advance  of  the 
disease  is  thus  abolished. 

Abortion  may  be  induced  by  puncture  of  the  membranes,  if  this 
is  practicable.  If  not,  the  cervix  may  be  first  dilated  by  a  lamiuaria 
tent.  In  the  first  three  or  four  months  this  will  generally  be 
necessary.  Antiseptic  precautions  must  be  used  with  special 
strictness,  on  account  of  the  risk  of  sepsis  caused  by  pressure  of  a 
tent  upon  cancerous  tissue. 

During  labour  coming  on  spontaneously,  in  cases  in  which 
the  growth  does  not  admit  of  extirpation,  fair  time  should  be 
allowed  to  nature  to  see  what  dilatation  and  softening  of  the  cervix 
will  take  place  before  further  interference  is  undertaken.  Hydro- 
static dilators  have  sometimes  been  used  to  stretch  the  cervix,  but 
not  with  very  favourable  results.  It  seems  that  their  prolonged 
pressure  is  more  likely  to  cause  inflammation  of  the  growth  or 
septic  absorption  than  are  lacerations  or  incisions. 

Incision  of  the  Cervix. — In  cases  which  end  favourably  by  the 
natural  powers,  the  yielding  often  takes  place  by  spontaneous 
laceration.  This  may  be  imitated  by  artificial  incisions  with 
advantage,  the  main  mass  of  the  growth  being  first  removed  by 
the  curette  or  cautery,  and  the  general  results  of  cases  so  treated 
have  been  good.  Hemorrhage  either  from  lacerations  or  incisions 
has  not  generally  been  very  formidable.  It  may  be  arrested  if 
necessary  by  swabbing  with  a  solution  of  perchloride  or  subsulphate 
of  iron.  The  method  of  incision  is  applicable  chiefly  when  the 
disease  is  mainly  in  the  cervix  itself,  not  so  much  when  there  is  a 
large  hard  mass  in  the  cellular  tissue  outside.  In  one  case  of 
cancer  involving  the  whole  cervix,  I  incised  in  several  directions  up 
to  the  vaginal  reflection,  and  then  removed  the  intervening  portions 
by  the  galvanic  ecraseur.  Delivery  followed  very  rapidly  by  the 
natural  powers,  the  child  being  alive. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    653 

If  necessary  the  incisions  may  be  made  according  to  the  method 
of  the  so-called  vaginal  Csesarean  section  (see  Chapter  XXXVL), 
the  bladder  being  first  stripped  up  from  the  front  of  the  uterus  as 
in  vaginal  hysterectomy,  and  the  peritoneum  of  the  pouch  of  Douglas 
from  the  back.  Sagittal  incisions  are  then  made  in  the  centre  of 
the  anterior  and  posterior  walls. 

Forceps  and  Version. — Delivery  by  forceps  or  version  may  be 
combined,  if  necessary,  with  the  method  of  incisions,  especially  if 
the  pains  are  not  strong.  Of  the  two,  forceps  give  rather  a  more 
favourable  chance  to  the  child.  Version,  especially  by  the  bipolar 
method,  can  be  performed  when  the  os  is  too  small  for  aiDplication 
of  forceps  to  be  desirable,  and  the  half-breech  then  forms  an 
efficient  wedge-shaped  dilator.  In  9  cases  delivered  by  forceps  there 
were  4  deaths ;  in  14  deliveries  by  version  8  deaths  (Herman). 

Craniotomy  and  Cesarean  Section. — Before  the  introduction  of 
Sanger's  method  of  Csesarean  section,  craniotomy  and  Csesarean 
section  both  gave  a  very  high  mortality,  one  of  from  70  to  80  per 
cent.,  with  not  very  much  to  choose  between  them.  With  the 
improved  method  of  Csesarean  section  the  results  are  improved,  but 
not  nearly  equal  to  those  obtained  in  cases  of  pelvic  contraction, 
partly  on  account  of  the  septic  material  produced  by  the  cancer, 
partly  on  account  of  the  depressed  constitutional  condition  of  the 
patient.  Where  the  whole,  or  nearly  the  whole,  circuit  of  the  os  is 
diseased,  or  much  of  the  cellular  tissue  infiltrated,  C^esarean  section 
gives  the  best  chance  for  the  child  and  is  the  least  dangerous 
method  of  delivery  for  the  mother  when  undertaken  as  a  primary 
choice.  Perhaps  the  best  method  in  this  case  is  to  perform  the  old- 
fashioned  Porro  operation,  with  external  treatment  of  the  pedicle 
(see  Chapter  XXXVL),  by  which  the  uterine  cavity  is  isolated  from 
the  peritoneum  and  its  neighbourhood.^  The  mortality  of  these 
operations,  if  undertaken  during  labour,  whether  the  uterus  be 
removed  or  not,  is  undoubtedly  very  high,  54  to  60  per  cent.,^  but 
it  should  be  much  less  if  they  are  performed  during  pregnancy 
before  labour  has  come  on.  In  such  cases  the  growth,  either 
previously  or  at  the  same  time,  should  be  curetted  and  cauterised. 
If  attempts  have  already  been  made  to  extract  by  forceps  or  by 
version,  craniotomy  is  generally  preferable. 

Labour  Complicated  by  Tumours. 

FiBROMYOMATA,  OR  FiBRoiD  TuMOURs  OF  THE  Uterus.  —  Con- 
sidering the  frequency  of  fibroid  tumours,  it  is  comparatively  rare 

1  Bpcncer,  Trans.  Obst.  Soc.  London,  1904,  Vol.  XLVl.,  p.  355. 

2  Sarwey,  loc.  cit. 


654  The  Practice  of   Midwifery. 

for  them  when  of  large  size  to  be  met  with  as  a  compHcation  of 
labour ;  in  13,814  pregnancies  Meheut  records  85  cases,  or  0*62  per 
cent.  In  general,  fibroid  tumom's  appear  to  be  associated  with 
sterility — that  is,  sterile  women  tend  to  develop  fibroid  tumours. 
No  doubt  the  presence  of  fibroid  tumours  plays  a  part  in  the  pro- 
duction of  relative  sterility,  for  women  wdth  these  tumours  seldom 
have  more  than  one  or  two  children,  but  it  is  doubtful  if  they  are 
really  an  etiological  factor  in  the  production  of  absolute  sterility. 
As  a  rule,  the  sterility  antedates  the  time  at  which  the  presence  of  a 
fibroid  tumour  causes  any  symptoms.  The  tumours  may  have  some 
effect  in  producing  abortion  or  premature  labour,  but  not  so  fre- 
quently as  has  been  supposed.  The  dangers  to  which  a  fibroid  tumour 
complicating  labour  may  lead  are  inefficient  or  irregular  contrac- 
tions of  the  uterus,  ante-partum,  or  more  frequently  i)ost-imrtum, 
haemorrhage — the  latter  depending  upon  the  failure  of  the  uterus 
to  contract — obstruction  to  the  passage  of  the  foetus  when  the 
tumour  occupies  the  pelvis,  rupture  of  the  uterus  from  the  com- 
bined effect  of  the  obstruction  and  partial  atrophy  or  weakness  of 
the  uterine  muscle,  subsequent  inflammation  or  sloughing  of  the 
growth  from  the  effect  of  bruising  or  pressure,  with  consequent 
risk  of  septicaemia,  and  very  rarely  inversion  of  the  uterus.  Uterine 
contractions  are  apt  to  be  unusually  painful.  A  fibroid  tumour 
also  appears  to  predispose  to  malpresentations  and  placenta  praevia, 
and  may  then  render  version  or  other  treatment  difficult,  if  the 
fibroid  occupies  the  lower  part  of  the  uterus. 

If  the  fibroids  are  corporeal  and  subserous,  especially  if  pedun- 
culated, generally  labour  is  but  little  disturbed,  unless  their  size 
is  so  great  as  to  interfere  with  the  action  of  auxiliary  muscles.  If 
they  are  interstitial,  or  submucous,  the  chief  risk  of  haemorrhage 
occurs,  since  the  due  contraction  of  the  uterus  is  then  apt  to  fail. 
If  a  fibroid  obstructs  labour  by  occujDying  the  pelvis,  it  generally  lies 
behind  the  cervix  (see  Fig.  323).  It  may  then  be  either  a  corporeal 
sub-peritoneal  fibroid  which  has  dropped  down  into  the  j)elvis,  or  a 
sub-peritoneal  outgrowth  from  the  cervix.  The  latter  is  much  the 
more  serious,  since  it  cannot  be  pushed  up  out  of  the  pelvis.  Labour 
may  also  be  obstructed  by  a  large  fibroid  polypus,  coming  down  in 
advance  of  the  presenting  part,  by  a  submucous  fibroid  in  the 
lower  part  of  the  uterus  or  cervix,  or  by  a  general  fibroid  elongation 
and  enlargement  of  the  cervix,  generally  of  the  anterior  lip.  Fibroids 
generally  enlarge  with  the  stimulus  of  pregnancy,  and  they  may  at 
the  same  time  become  soft  from  oedema  or  cystic  formation.  In 
such  case  the  growth  may  be  difficult  to  distinguish  from  an 
ovarian  tumour. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.    655 

Treatment. — If  the  fibroids  are  corporeal,  and  do  not  occupy  the 
pelvis,  all  that  is  generally  necessary  is  to  take  special  pains  to 
secure  due  contraction  of  the  uterus  in  the  third  stage  of  labour  and 
afterwards.  It  is  well  to  give  a  dose  of  ergot  after  delivery.  If  a 
subserous  fibroid  occupies  the  pelvis,  so  as  to  obstruct  the  passage 
of  the  fcetus,  the  first  effort  should  be  to  push  it  up  out  of  the 
pelvis.     By  this  means   the  necessity  for  Csesarean  section  may 


Fig.  323. — Diagrammatic  drawing  of  case  of  retroflexion  of  the  uterus  at  full 
term  caused  by  a  fibromyoma  adherent  in  Douglas'  pouch,  treated  by 
Cassarean  section  and  total  abdominal  hysterectomy.  The  posterior  wall  is 
much  thicker  than  the  anterior,  and  the  fibroid  is  attached  to  the  posterior 
wall  at  the  fundus  uteri.i 

sometimes  be  averted.  The  attempt  may  first  be  made  with  the 
patient  in  the  knee-elbow  position,  with  the  fingers  in  the  vagina, 
or,  if  that  fails,  in  the  rectum.  If  this  also  fails,  an  ansesthetic 
should  be  administered,  and  the  attempt  rej)eated  with  the  patient 
in  the  semi-prone  position.  It  is  sometimes  of  service  to  introduce 
two  fingers  or  even  the  half-hand  into  the  rectum.  If  a  fibroid 
tumour  occupies  the  lower  segment  of  the  uterus  so  as  to  obstruct 
the  passage  of  the  fa^us,  and  cannot  be  pushed  up  above  the  brim, 

1  Univ.   0(j11.  Hosi).   Med.  School  Mas.      See  Spencer,   Proc.   Obsfc.  Sect.  Koy.  See. 
Mod.,  Vol.  II.,  p.  74. 


656  The  Practice  of   Midwifery. 

it  is  well  to  let  labour  come  on  and  progress  to  some  extent,  short 
of  the  rupture  of  the  membranes.  For  in  some  cases,  with  com- 
mencing dilatation  of  the  os,  the  tumour  becomes  elevated  unex- 
pectedly above  the  brim,  and  delivery  becomes  easy  in  cases  in 
which  Cesarean  section  had  appeared  inevitable. 

If  this  does  not  occur,  and  in  cases  in  which  it  is  recognised  from 
the  first  that  the  fibroid  is  cervical,  and  cannot  be  elevated  out  of 
the  way,  Csesarean  section  should  be  selected  as  a  first  choice.  In 
general  this  should  be  followed  by  removal  of  the  uterus,  either  by 
supra-vaginal  hysterectomy  or  panhysterectomy  according  to  the 
position  of  the  tumour.  In  this  way  the  tumour  is  cured,  and  the 
risk  is  little,  if  at  all,  increased.  In  some  cases,  in  which  there  is 
single  tumour  with  a  narrow  neck,  the  tumour  may  be  removed  by 
myomectomy  and  the  uterus  preserved. 

If  the  case  is  only  seen  when  the  membranes  have  already  been 
long  ruptured,  it  may  be  preferable  to  deliver  by  craniotomy, 
followed  by  the  use  of  the  cephalotribe,  provided  that  the  tumour 
leaves  room  enough  in  the  pelvis  to  allow  it  without  great  risk. 
For  this  purpose  there  should  be  a  space  measuring  at  least 
2|  inches  in  its  smallest  diameter,  and  4  inches  in  the  diameter 
bisecting  the  former  at  right  angles. 

If  a  case  comes  under  observation  before  full  term,  a  trial  should 
be  made  whether  the  tumour  can  be  pushed  up  out  of  the  pelvis. 
If  this  is  not  the  case,  it  is  generally  advisable  to  let  the  patient  go 
on  to  full  term,  and  then  perform  Caesarean  section  and  hysterectomy 
if  required.  If  the  patient  refuses  this  alternative,  it  may  be 
justifiable  to  induce  abortion,  but  this  may  involve  serious  risk  if 
the  tumour  interferes  with  the  removal  of  the  placenta.  In  some 
cases,  in  which  the  tumour  is  very  large  and  pressure  symptoms 
arise  during  pregnancy,  hysterectomy  may  be  called  for  before 
full  term.  In  all  cases  whenever  possible  operation  should  be 
postponed  till  the  child  is  viable.  Care  must  be  taken  not  to 
mistake  the  sac  of  an  extra-uterine  pregnancy,  which  generally  lies 
behind  the  uterus,  for  a  fibroid  or  ovarian  tumour  complicating 
uterine  pregnancy. 

Enucleation. — In  the  case  of  a  submucous  fibroid  presenting 
at  the  lower  part  of  the  uterus  below  the  foetus,  enucleation 
of  the  fibroid  before  delivery  may  be  the  best  treatment,  if 
delivery  is  likely  to  be  otherwise  very  difiicult.  If  there  is  any 
constriction  at  the  lower  margin  of  attachment,  forming  a  demarca- 
tion between  the  tumour  and  the  uterine  wall,  this  may  generally 
be  efl'ected.  The  mucous  membrane  may  be  incised  with  scissors 
along    the    lower  margin    of   attachment,   and    the  tumour   then 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.   657 


enucleated  as  a  whole,  or,  if  necessary,  after  morcellation.  A  sagittal 
incision  may  be  made  through  the  anterior  or  posterior  lip  of  the 
cervix,  as  in  vaginal  Caesarean  section.  Traction  upon  the  tumour, 
by  means  of  strong  tenaculum  forceps  fixed  into  it,  will  assist  the 
operation.  It  is  necessary  for  the  safety  of  this  operation  that  there 
should  be  a  sufficient  thickness  of 
uterine  wall  covering  the  tumour 
outside. 

If  fibroid  enlargement  of  the  an- 
terior lip  is  likely  to  cause  much 
obstruction,  it  may  be  amputated 
before  delivery.  A  fibroid  polypus  is 
a  much  less  formidable  complication. 
It  can  easily  be  removed  with 
scissors,  before  delivery.  If  a  polypus 
is  detected  only  after  delivery,  it 
should  still  be  at  once  removed,  lest 
sloughing  should  occur,  and  con- 
sequent septic  absorption. 


OvAEiAN  Tumours.  —  An  ovarian 
tumour  in  the  abdomen  does  not 
generally  interfere  with  labour  further 
than  by  making  the  pains  less  effec- 
tive. Delivery  by  forceps  may  be 
called  for  on  this  account.  If  an 
ovarian  tumour  lies  in  the  pelvis 
behind  the  cervix,  it  is  liable  to 
obstruct  delivery  like  a  fibroid  in  the 
same  position  (Fig.  324).  It  is  still 
more  likely  than  a  fibroid,  in  con- 
sequence of  the  pressure  to  which  it 
is  subjected,  to  undergo  inflammatory  or  necrotic  processes  after- 
wards, or  to  rupture  into  the  peritoneal  cavity.  Of  263  recorded 
cases  collected  by  McKerron,^  56,  or  30"5  per  cent.,  ended  fatally. 

Treatment. — The  ideal  and  undoubtedly  the  best  treatment  for 
ovarian  tumours  in  the  pelvis  obstructing  labour  is  immediate 
ovariotomy.  If  the  conditions  are  impossible  for  carrying  out  this 
operation,  then  an  attempt  may  be  made  to  push  the  tumour  up  out 
of  the  pelvis,  great  care  being  taken  and  no  undue  force  being 
employed.     If  this  manoeuvre  fails,  then  the   tumour   should   be 


Fig.  324. — Diagrammatic  drawing 
of  a  dermoid  tumour  of  the 
right  ovary  obstructing  labour. 
Ovariotomy  was  performed 
during  labour,  and  delivery 
effected  by  forceps.  (Univ. 
Coll.  Hosp.  Med.  School 
Mus.)i 


'  Sec  Spencer.  Trans.  Obst.  Soc.  London,  1898,  Vol.  XL.,  p.  U. 

'■^   McKerron,  Pregnancy,  Labour,  antl  Childbed  with  Ovarian  Tumour,  UJ08,  p.  1G9. 

M.  42 


658  The  Practice  of   Midwifery. 

punctured  through  the  vagina,  if  it  appears  to  consist  mainly  of  a 
single  cyst.  For  the  puncture  an  aspirator  may  be  used,  with  not 
too  small  a  needle,  lest  the  fluid  prove  to  be  thick  and  tenacious. 
The  vagina  should  first  be  syringed  with  an  antiseptic  solution, 
and  the  aspirator  needle  sterilised  by  heat.  If  simple  puncture  fails 
to  get  rid  of  the  obstruction,  or  if  the  physical  signs  suggest  that 
the  tumour  is  semi-solid  or  a  dermoid,  it  should  be  incised,  and 
the  cyst  cavity  packed  with  gauze.  In  all  cases,  whether  the 
tumour  be  pushed  up,  punctured,  or  incised,  as  soon  as  possible 
after  delivery  the  remains  of  it  should  be  removed  by  abdominal 
ovariotomy. 

If  the  tumour  is  solid  or  semi-solid,  and  the  obstruction  cannot 
be  got  rid  of  by  incision,  it  must  be  removed  either  by  the  abdomen 
or  by  the  vagina  before  the  child  is  delivered.  In  performing 
ovariotomy  in  these  cases  a  long  incision  should  be  made  and  the 
uterus  turned  out  of  the  abdomen.  The  ovarian  tumour  is  then 
removed,  the  uterus  replaced,  and  labour  left  to  be  completed 
naturally.  In  cases  in  which  the  ovarian  tumour  partly  occupies 
the  abdomen,  it  may  be  possible  to  perform  ovariotomy  without 
turning  out  the  uterus.  Cfesarean  section  should  not  be  practised 
unless  it  is  found  impossible  to  remove  the  tumour  without  first 
emptying  the  uterus.  As  a  general  rule,  abdominal  ovariotomy 
should  be  performed,  and  not  vaginal ;  but  in  a  few  cases  it  may 
be  found  possible  after  its  incision  to  remove  the  tumour  by  the 
vaginal  route. 

Hydatid  tumours  of  the  pelvis  are  of  rare  occurrence  in  Britain, 
but  may  possibly  form  an  obstruction  to  labour  like  an  ovarian 
tumour.^  The  nature  of  the  tumour  could  hardly  be  diagnosed 
before  puncture,  unless  from  the  presence  of  a  similar  tumour  in 
connection  with  the  liver,  or  in  other  parts.  The  obstruction  caused 
by  the  tumour  will  generally  be  overcome  by  puncture. 

Congenital  abnormality  of  kidney,  in  which  the  kidney  is 
situated  centrally  in  the  lumbar  region,  has  been  recorded  as  a 
cause  of  obstruction  to  labour,  and  rupture  of  the  uterus. 

Prolapse  of  the  Vagina.— When  the  vagina  has  been  prolapsed 
before  pregnancy  or  during  pregnancy,  the  hypertrophied  tissue, 
especially  the  anterior  vaginal  wall,  may  be  pushed  down  in  front 
of  the  head,  become  oedematous  from  pressure,  and  cause  a  certain 
amount  of  obstruction.  Sometimes  a  pouch  of  the  bladder,  forming 
a  cystocele,  descends  with  the  vagina.  If  this  contains  urine,  a 
tense   swelling,    causing   increased   obstruction,   may   be    formed. 

'  Blacker,  Journ.  Obst.  aud  Gyn.  Brit.  Emp.,  November,  1908,  p.  33fi. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.   659 

The  treatment  is  to  empty  the  bladder  by  catheter,  and  retract 
the  prolapsed  mucous  membrane  with  the  fingers  as  the  head  is 
passing. 

Distended  Bladder. — Eetention  of  urine,  from  pressure  of  the 
presenting  part  on  the  neck  of  the  bladder,  is  not  uncommon  in 
labour.  The  top  of  the  bladder  rises  in  the  abdomen  with  the 
lengthening  of  the  cervix  and  upward  travelling  of  the  internal  os 
uteri.  If  the  abdomen  be  examined,  therefore,  a  distended  bladder 
is  always  easily  recognised  as  an  elastic  fluctuating  swelling  in 
front  of  the  lower  part  of  the  uterus.  Its  effect  in  rendering  pains 
ineffective  has  already  been  considered  (see  p.  623).  In  passing  a 
catheter  it  must  be  remembered  that  the  meatus  is  often  displaced 
forward  by  swelling  and  descent  of  the  vaginal  wall,  and  the  urethra 
lengthened  by  stretching.  The  urine,  moreover,  is  contained  only 
in  the  upper  part  of  the  bladder.  It  is  preferable,  therefore,  to 
use  not  a  short  female  catheter,  but  an  elastic  male  catheter.  If 
the  catheter  is  arrested  at  the  point  where  the  head  rests  against 
the  pubes,  the  head  should  be  pushed  up  in  an  interval  between 
pains,  and  the  tip  of  the  catheter  guided  forward  by  the  finger  in 
the  vagina  so  as  to  pass  the  head. 

Vesical  Calculus. — Calculus  is  very  rare  in  women,  and  still 
rarer  as  a  complication  of  labour.  Cases  have,  however,  been 
recorded  in  which  a  calculus  has  become  impacted  between  the 
descending  head  and  the  pubes,  or  fixed  at  the  entrance  of  the 
urethra,  and  formed  an  obstacle  to  labour.^  The  diagnosis,  if  any 
doubt  existed,  would  be  at  once  decided  by  the  use  of  the  bladder 
sound. 

Treatment, — The  calculus  should,  if  possible,  be  pushed  out  of 
the  way  above  the  pubes.  The  elevation  of  the  bladder  in  labour 
will  generally  facilitate  this.  If  it  does  not  otherwise  succeed,  the 
attempt  should  be  repeated  in  the  knee-elbow  position,  the  head 
being  pushed  backward.  If  the  calculus  is  firmly  impacted  and 
cannot  be  pushed  up,  it  may  be  extracted  after  rapid  dilatation  of 
the  urethra,  if  small.  If  it  is  large,  vaginal  lithotomy  may  be 
performed,  if  necessary,  by  a  longitudinal  incision,  and  the  wound 
closed  by  sutures  when  delivery  is  completed. 

Vaginal  Enterocele. — Prolapse  of  the  posterior  vaginal  wall, 
independent  of  pregnancy,  is  often  accompanied  by  rectocele. 
Much  more  rarely  some  portion  of  the  small  intestine,  omentum, 

1  Hmellie's  Treatise  of  Midwifery,  Vol.  II.,  p.  100,  case  60  ;  Hugenberger,  Petersburg 
Med.  Zeitsch.,  1875,  Bd.  .5. 

42—2 


66o 


The  Practice  of   Midwifery. 


or  some  part  of  the  large  intestine,  as  the  sigmoid  flexure,  descends 
into  the  pouch  of  Douglas,  which  is  always  drawn  down  into  the 
swelling  (Fig.  325).  Thus  a  kind  of  vaginal  hernia  is  formed.  In 
rare  cases,  such  an  enterocele  may  be  pushed  down  in  front  of  the 
head  in  labour,  and  its  return  prevented  by  the  pressure.  Such  a 
swelling  will  be  resonant,  wdth  gurgling  on  pressure.  The  diagnosis 
will  be  made  certain  by  combined  vaginal  and  rectal  examination. 
The  treatment  is  to  return  the  hernia  by  pressure,  with  the  aid,  if 
necessary,  of  the  knee-elbow  position,  the  head  being  pushed 
backw^ard.  If  this  does  not  succeed,  the  attempt  may  be  made 
with  the  aid  of  chloroform,  the  patient  being  in  the  semi-prone 
position.     This  also  failing,  delivery  may  be  hastened  with  forceps. 


HEMATOMA,  OR  Thrombus  OF  THE  Vagina  AND  VuLVA. — Thrombus 

of  the  vagina  or  vulva  arises 
from  rupture  of  veins  or  capil- 
lary vessels.  It  rarely  occurs  in 
pregnancy,  unless  from  the  effect 
of  violence,  more  frequently  in 
actual  labour  or  after  delivery. 
The  predisposing  causes  are,  first 
the  vascular  distension  of  preg- 
nancy, next  the  obstacle  to 
venous  return  from  pressure  of 
the  presenting  part,  and  finally 
the  increased  venous  pressure 
due  to  the  bearing-down  efforts. 
The  actual  tearing  of  the  vessels 
is  due  to  the  bruising  and  drag- 
ging of  the  tissues  by  the 
presenting  part,  to  operative  interference,  or  to  some  external 
violence,  such  as  a  fall  or  blow.  In  some  cases  a  tense  swelling  is 
produced  large  and  hard  enough  to  form  an  obstacle  to  delivery.  In 
others  the  swelling  is  comparatively  small,  or  only  becomes  manifest 
after  delivery.  The  surface  may  rupture  from  tension  or  be  lacerated 
in  delivery,  and  then  profuse  haemorrhage  may  occur,  even  to  such 
an  extent  as  to  prove  fatal.  Afterwards  there  is  danger  of  septi- 
caemia from  breaking  down  of  the  effused  clot,  especially  if  exposed 
to  the  air.  Most  frequently  the  effusion  commences  close  to  the 
vaginal  outlet  on  one  side,  and,  limited  by  the  attachment  of  the 
pelvic  fascia,  extends  some  little  way  up  the  vagina  and  outwards 
toward  the  labia.  Occasionally  the  blood,  tearing  through  the 
attachment  of  the  fascia,  extends  up  in  the  cellular  tissue  surrounding 


Fig.  325. — Prolapse  of  posterior  vaginal 
wall  with  enterocele. 


Labour  Obstructed  by  Anomalies  of  Soft  Parts.  66 1 

the  vagina,  on  to  the  iliac  fossae,  even  up  to  the  neighbourhood 
of  the  kidneys,  or  along  the  anterior  abdominal  wall.  Still  more 
rarely  instances  have  been  recorded  of  subperitoneal  hsematomata 
affecting  not  the  lower  part  of  the  vagina,  but  beginning  in  the 
tissues  round  the  cervix  and  simulating  the  effusions  of  blood  met 
with  in  some  cases  of  incomplete  rupture  of  the  lower  uterine 
segment.^ 

In  hsematoma  of  the  vulva  or  vagina,    the   swelling   generally 
increases  rapidly  and  is  accompanied  by  acute  tearing  pain  in  the 


Fig.  326. — Coronal  section  of  the  pelvis  (diagramraatic),  showing  the  usual 
anatomical  situation  of  a  hsematoma  of  the  vulva,  and  of  a  subperitoneal 
hematoma,  and  the  manner  in  which  the  extension  of  the  first 
upwards,  and  of  the  second  downwards,  is  prevented  by  the  attachment 
of  the  pelvic  fascia  to  the  vaginal  walls. 

part  affected,  and  extending  to  the  thigh.  Marked  symptoms  of 
anfemia  may  appear  at  the  same  time.  If  the  lesion  is  caused  by 
the  head  itself,  the  effusion  may  be  kept  in  check  by  pressure,  and 
only  increases  more  gradually  after  delivery  is  completed.  The 
swelling  is  tense  but  fluctuating,  while  the  blood  remains  fluid,  the 
surface  dark  blue  and  translucent.  As  clot  forms  the  swelling 
becomes  harder.  The  vagina  may  be  so  much  narrowed  as  to 
impede  the  escape  of  the  lochia.  The  surface  may  give  way  only 
after  an  interval  of  some  days,  and  then  there  is  danger  of  recurrent 
haemorrhage.      The  suppuration  which  follows  rupture  or  artificial 

'  W.  Williams,  Trans.  Am.  Gyii.  Hoc,  1904,  Vol.  XXIX.,  p.  186. 


662  The  Practice  of   Midwifery. 

opening  may  lead  to  necrosis  of  tissue  round,  or  burrowing  abscesses, 
as  well  as  to  septicaemia.  In  favourable  cases  resolution  occurs 
without  rupture. 

Thrombus  of  vagina  or  vulva  does  not  occur  more  than  once  in 
2,000  or  3,000  deliveries.  As  a  cause  of  obstruction  to  labour,  it 
is  very  much  more  rare  even  than  this.  When  the  effusion  is 
extensive,  the  prognosis  is  a  rather  serious  one.  In  50  cases 
collected  by  Von  Winckel  ^  there  were  6  deaths,  or  12  per  cent.,  and 
other  authorities  have  given  a  much  more  unfavourable  estimate 
than  this.  In  the  favourable  circumstances,  however,  attending  the 
treatment  of  such  cases  at  the  present  time,  the  results  will  be  much 
better. 

Treatment. — If  the  commencing  formation  of  a  thrombus  in 
labour  is  detected  early,  the  foetus  should  be  extracted  with  forceps 
as  quickly  as  possible,  since  the  relief  of  venous  obstruction  is  the 
best  means  to  stop  the  bleeding.  If  the  swelling  is  so  large  as  to 
prevent  delivery,  it  must  be  first  incised.  The  bleeding  may  be 
stopped  by  j)lugging  with  antiseptic  gauze  or  by  drawing  the  head 
quickly  down  upon  the  opening.  Bleeding  after  delivery  must  be 
stopped  in  the  same  way.  Dangerous  bleeding  may  be  kept  in 
check  by  pressure  with  the  finger  alone,  while  the  gauze  is  being 
obtained.  Eecurrent  bleeding  is  to  be  treated  in  a  similar 
manner. 

If  the  delivery  is  over,  and  the  thrombus  is  not  ruj)tured,  it 
should  be  left  unopened  if  possible.  The  thrombus  should  only  be 
incised  if  the  surface  is  becoming  sloughy,  if  there  are  signs  of 
suppuration  in  it,  or  general  signs  of  septic  absor^Dtion  attributed 
to  its  presence,  or  again  if  the  swelling  is  so  enormous  that  there 
is  no  hope  of  its  absorption.  Even  a  delay  of  a  few  days  in  opening 
is  an  advantage,  for  there  is  then  less  risk  of  recurrent  haemorrhage. 
If  an  opening  is  made,  it  should  be  fairly  free,  and  at  a  prominent 
yet  dependent  part,  generally  at  the  inner  side  of  the  labium 
majus.  All  blood  clot  should  be  removed,  the  cavity  irrigated  with 
a  weak  antiseptic  lotion,  and  plugged  with  antisej)tic  gauze.  Any 
sloughy  and  loose  bits  of  tissue  should  be  removed. 

^  Pathologie  unci  Therapie  des  Wochenbettes,  English  translation,  Chadwick,  1876, 
p.  148. 


Chapter  XXVIII. 

LABOUR  OBSTRUCTED  BY  ANOMALIES   OF  THE 

OVUM, 

Shoulder,  Arm,  and  Transverse  Presentations. 

Although  the  term  "  transverse  presentation  "  or  "  crossbirth  " 
is  frequently  used,  it  is  very  rare  for  the  long  axis  of  the  foetus  to 
lie  transversely  in  the  uterus,  either  in  pregnancy  or  at  the  onset 
of  labour.  Almost  the  only  case  in  which  the  foetus  actually  lies 
transversely  is  that  in  which  the  abdomen  is  so  contracted  from 
above  downwards  in  consequence  of  spinal  deformity  that  there  is 
more  room  for  the  axis  of  the  foetus  in  a  transverse  than  in  its  usual 
position.  The  shape  of  the  uterus  then  accommodates  itself  to  the 
necessity  of  the  case.  In  the  cases  often  called  "  transverse 
presentations,"  the  axis  of  the  foetus  for  the  most  part  really  lies 
obliquely  in  the  first  instance,  the  head  lower  than  the  breech. 
The  head  is  then  displaced  to  one  side  of  the  brim  instead  of 
descending  into  it,  and  the  shoulder  becomes  usually  at  first 
the  presenting  part.  As  the  shoulder  is  pressed  more  deeply 
into  the  brim,  the  head  is  deflected  more  and  more  upwards, 
and  the  long  axis  of  the  child  becomes  more  nearly  transverse 
than  at  first.  After  the  rupture  of  the  membranes  the  lower  arm 
is  prolapsed  in  about  50  per  cent,  of  the  cases,  the  upper  in 
4*2  per  cent.,  and  so  becomes  the  presenting  part  (Fig.  327,  p.  664), 
but  the  mechanism  is  not  essentially  different,  whether  the  shoulder 
or  arm  presents.  More  rarely  other  parts  of  the  foetus  present, 
such  as  the  back,  or  the  abdomen,  the  foetus  in  the  latter  case  being 
in  a  position  of  excessive  extension  or  opisthotonos,  instead  of  the 
usual  position  of  flexion.  These  presentations  occur  chiefly  with  a 
j)remature  or  macerated  foetus,  which  is  apt  to  become  doubled  up 
in  various  positions.  They  have  a  tendency  to  become  converted 
into  shoulder  presentations.  In  rare  cases  the  so-called  compound 
presentations  occur,  such  as  hands  and  feet  together,  or  feet  with 
head.  In  these  cases  the  axis  of  the  foetus  may  have  considerable 
oljliqiiity  or  be  nearly  transverse,  or  it  may  be  much  doubled  ui)on 
itself.  The  presentation  of  feet  with  head  impHes  that  the  legs  are 
extended  upon  the  thighs  instead  of  being  flexed  as  usual. 


664 


The  Practice  of   Midwifery. 


In  all  these  presentations  the  foetus  is  moulded  into  such  a  shape 
that  it  forms  a  wedge  with  the  base  uppermost,  the  dimensions  of 
the  base  being  as  a  rule  so  large  that  it  cannot  possibly  pass 
through  the  pelvis.  In  the  case  of  shoulder  or  arm  presentation 
the  base  of  the  wedge  is  formed  by  the  diameter  of  the  head  in 
addition  to  that  of  the  thorax.  As  a  rule,  therefore,  delivery  is 
impossible,  except  by  artificial  means. 


Frequency. — The  frequency  of  shoulder  or  transverse  presenta- 
tion in  its  different  varieties  has  been  estimated  at  from  1  in  130  to 
1  in  250  cases.     In  the  Guy's  Hospital  Charity  it  was  1  in  354,  in 

49,588  births.  Pinard 
records  804  in  100,000 
cases,  or  1  in  125,  Koutier^ 
1  in  127. 

Causation. — All  abnor- 
mal, and  especially  oblique 
and  transverse,  positions  of 
the  foetus  are  relatively 
common  in  pregnancy  before 
full  term,  and  tend  to 
become  rectified  by  the 
mutual  adaptation  of  the 
uterus  and  the  foetus,  as 
previously  described  (see 
p.  143).  Immaturity  of  the 
foetus  is  therefore  an  impor- 
tant cause  of  shoulder 
presentations,  as  25  per  cent,  of  all  transverse  presentations  are  met 
with  in  premature  births.  Another,  accounting  for  about  10  per 
cent,  of  the  cases,  is  death  or  maceration  of  the  foetus,  for  then  the 
tonicity  by  which  it  maintains  its  axis,  and  the  muscular  movements 
by  which  adaptations  are  aided,  both  fail.  In  the  development  of 
shoulder  presentations  out  of  a  slightly  oblique  position  of  the  long 
axis,  contraction  of  the  pelvic  brim,  especially  contraction  of  the 
conjugate  diameter,  plays  an  imj)ortant  part.  For  if  the  foetal  head 
is  unable  easily  to  enter  the  brim,  it  is  more  likely  to  be  deflected 
to  one  side  toward  the  iliac  fossa.  If,  on  the  other  hand,  it  can  lie 
deeply  in  the  pelvis  before  the  onset  of  labour,  its  displacement  is 
unlikely.     Thus  women  who  have  a  contracted  pelvis  are  liable  to 

1  Routier,  De  la  Termiaaison  Spontanfe  de  I'Accouchement  dans  la  Presentation  de 
I'Epaule,  1893. 


Fig.  327. — Arm  presentation  in  the  dorso- 
anlerior  position. 


Labour  Obstructed  by  Anomalies  of  Ovum.     665 

have  shoulder  presentations  recurring  in  successive  labours.  In 
conjunction  with  pelvic  contraction  sufficient  to  keep  the  head 
above  the  brim,  obliquity  of  the  uterus  is  an  imj)ortant  cause.  The 
uterine  force  being  oblique  tends  to  push  the  head  toward  the 
opposite  iliac  fossa.  Thus  the  head  lies  more  frequently  in  the 
left  iliac  fossa,  and  this  fact  is  probably  explained  by  the  fundus 
uteri  being  generally  oblique  toward  the  right. 

Other  causes  are  those  which  act  by  interfering  with  the  natural 
adaptation  of  the  fcetus  to  the  shape  of  the  uterus  through  uterine 
contractions.  These  are  laxity  or  weakness  of  the  uterine  muscle, 
excess  of  liquor  amnii,  twin  pregnancy,  and  want  of  space  in  the 
abdomen  due  to  spinal  deformity.  Laxity  of  the  uterine  muscle 
may  be  one  reason  for  shoulder  presentation  being  relatively 
common  in  multiparse,  90  to  92  per  cent,  of  the  cases  occurring  in 
them  as  compared  with  8  to  10  per  cent,  in  primiparae.  Other 
reasons  are  that  the  uterus  is  more  often  oblique  or  anteverted, 
from  diminished  tone  of  abdominal  walls,  and  that  the  head  does 
not  generally  lie  so  low  in  the  pelvis  before  labour,  on  account  of 
the  condition  of  the  cervix.  "When  liquor  amnii  is  excessive,  the 
uterine  action  has  little  effect  in  producing  adaptation  during  preg- 
nancy. If  the  fluid  escapes  gradually  on  rupture  of  the  membranes, 
rectification  may  then  be  effected.  If  it  escapes  suddenly,  the  foetus 
may  become  fixed  in  any  abnormal  position.  In  twin  pregnancy, 
not  only  is  the  force  of  adaptation  almost  abolished,  but  one  foetus 
may  displace  the  other  by  pressure.  In  placenta  prsevia  also  there 
is  a  greater  tendency  to  sboulder  presentation,  when  the  mass  of 
the  placenta  prevents  the  head  from  resting  so  low  in  the  uterus 
during  pregiiancy. 

In  19  per  cent,  of  cases  of  fibromyomata  of  the  uterus  transverse 
presentations  are  found,  and  they  appear  to  be  especially  common 
with  some  forms  of  maldevelopment  of  the  uterus.  Thus  Vogel^ 
records  nine  cases  of  uterus  arcuatus  among  eighty-six  transverse 
presentations,  and  in  29  per  cent,  of  all  cases  of  this  deformity  of 
the  uterus  transverse  presentations  occur. 

Varieties. — Shoulder  and  transverse  presentations  are  divided 
into  two  main  varieties  :  dorso-anterior,  in  which  the  back  of  the 
child  is  directed  forward  (see  Fig,  327),  and  abdomino-anterior, 
in  which  the  abdomen  is  directed  forward  (see  Fig.  328,  p.  666). 
Each  of  these  again  is  divided  into  two  varieties,  according  as  the 
head  lies  in  the  right  or  the  left  iliac  fossa.  In  most  cases  the 
back  is  not  directed  precisely  backward  or  forward,  but  somewhat 

1  Vogel,  Zeitschr.  f.  Gcb.  u.  Uyn.,  1900,  Bd.  43,  p.  312. 


666 


The  Practice  of   Midwifery. 


obliquely,  as  in  the  cranial  positions  out  of  which  the  shoulder 
presentations  are  developed.  The  relative  frequency  of  the  varieties 
of  shoulder  presentation  is  in  accordance  with  that  of  the  different 
positions  of  the  vertex.  Thus  dorso-anterior  positions  are  more 
frequent  than  dorso-posterior,  occurring  in  three-fifths  of  all  cases. 
The  uterus  being  usually  rotated  somewhat  to  the  right,  the  trans- 
verse or  broadest  diameter  of  the  shoulders  generally  lies  nearly  in 
the  right  oblique  diameter  of  the  pelvis,  rather  than  exactly 
transversely.  Hence  the  head  generally  lies  somewhat  more 
forward  in  the  iliac  fossa  if  it  goes  toward  the  left  side  than  if  it 

goes  toward  the  right,  being 
displaced  laterally  in  refer- 
ence to  the  shoulders.  Pro- 
lapse of  the  funis  is  relatively 
common,  the  umbilicus  being 
brought  lower  than  normal, 
and  the  os  not  so  well  filled 
as  by  the  head. 


Fig.  328. — Arm  presentation  in  the 
abdomino-anterior  position. 


Diagnosis. — In  the  early 
stage  of  labour,  the  present- 
ing part  lies  higher  than 
usual,  and  may  on  that 
account  be  difiicult  to  reach 
or  to  make  out;  the  bag  of 
membranes  forms  a  longer 
and  less  wide  prominence 
than  usual ;  and  the  labour 
often  comes  on  slowly  and 
insidiously,  the  os  having 
less  stimulus  from  pressure.  After  the  rupture  of  the  membranes, 
the  pains  may  even  appear  to  subside.  This  sometimes  has  the 
unfortunate  result  that  the  accoucheur  is  not  sent  for  betimes. 

Transverse  or  oblique  positions  of  the  foetus  can  always  be  easily 
made  out  on  abdominal  palpation,  provided  that  the  uterus  is  lax 
and  the  abdominal  walls  not  excessively  thick  from  fat ;  and 
frequently  the  position  can  be  easily  changed  by  external  pressure 
only.-  Instead  of  one  broad  firm  portion  of  the  foetus — the  breech, 
being  felt  toward  the  fundus,  two  firm  portions — the  breech  and  the 
head,  are  felt,  and  these  are  displaced  toward  opposite  sides.  The 
head  generally  lies  in  one  or  other  iliac  fossa.  In  all  cases,  there- 
fore, in  which  the  presentation  cannot  be  made  out  on  vaginal 
examination,  or  in  which  shoulder   presentation   is   suspected,  a 


Labour  Obstructed  by  Anomalies  of  Ovum.     667 

careful  abdominal  examination  should  be  made.  If  the  membranes 
have  been  ruptured  for  some  time,  and  the  uterus  has  closed 
tightly  round  the  foetus,  it  is  more  difficult  to  make  out  the  head 
distinctly  through  the  hard  uterine  wall,  especially  if  it  lies  rather 
backward. 

It  is  of  the  greatest  importance  to  make  an  early  diagnosis  in 
shoulder  presentation,  so  that,  if  possible,  the  position  may  be 
rectified  before  the  rupture  of  the  membranes,  and  that,  at  any  rate, 
this  rectification  may  be  carried  out  before  the  uterus  has  become 
closely  contracted  round  the  child,  and  version  thus  rendered 
difficult.  If,  therefore,  the  presentation  cannot  be  made  out  with 
complete  certainty  by  one  or  two  fingers,  the  half-hand  or  whole 
hand  should  be  introduced  into  the  vagina  so  as  to  reach  high  in 
the  pelvis  and  settle  any  doubt.  The  examination  should  be  made 
only  in  the  absence  of  a  pain  and  when  the  membranes  are  quite 
lax,  lest  these  should  be  ruptured  prematurely.  If  pains  are 
frequent  and  vigorous,  it  is  well  to  administer  chloroform  for  the 
purpose.  Otherwise  the  reflex  stimulus  caused  by  the  hand  may 
excite  a  violent  pain  which  ru]3tures  the  membranes. 

The  shoulder  can  hardly  be  mistaken  for  anything  else  except 
the  breech,  a  mistake  which  I  have  known  to  be  made  with  disas- 
trous results.  The  distinctive  points  about  the  shoulder  are  the 
borders  of  the  axilla,  especially  the  ribs  below  it,  and  the  intercostal 
spaces,  the  "grid  of  the  ribs,"  which  are  quite  characteristic.  The 
spine  of  the  scapula  and  the  clavicle  will  also  be  felt.  On  the  other 
hand,  the  breech  is  positively  diagnosed  by  the  sacral  spines  and 
the  anus.  If  the  examining  finger  be  placed  in  the  axilla  it  will  be 
found  to  be  closed  in  the  direction  of  the  head  and  open  in  the 
direction  of  the  trunk  and  breech.  Indeed,  the  former  can  often  be 
reached  by  the  examining  hand.  The  positions  of  the  clavicle  and 
spine  of  the  scapula  will  show  whether  the  back  is  directed  forward 
or  backward. 

The  elbow  is  distinguished  from  the  knee  by  its  being  less 
broad,  and  having  the  sharp  projection  of  the  olecranon.  As  this 
distinction  is  not  always  quite  easy,  it  is  well  if  the  slightest 
doubt  exists,  and  the  membranes  are  already  ruptured,  to  bring 
down  the  hand  or  foot,  which  can  quite  readily  be  distinguished. 
The  measure  is  entirely  free  from  any  disadvantage  in  both  cases. 

The  hand  is  distinguished  from  the  foot  by  the  length  and 
mobility  of  the  fingers,  which  often  grasp  the  examining  finger, 
and  still  more  by  the  thumb,  separated  from  the  fingers,  and  the 
absence  of  the  prominence  of  the  heel.  The  most  characteristic 
points   about   the   foot   are   the   projection   of   the   heel   and   the 


668  The  Practice  of   Midwifery. 

malleoli  of  the  ankle.  To  distinguish  whether  right  hand  or  left 
is  presenting,  place  the  fingers  on  the  flexor  surface  of  the  hand 
as  in  shaking  hands.  If  then  the  thumb  is  directed  in  the  same 
way  as  the  thumb  of  the  examining  hand,  as  it  would  be  in 
shaking  hands,  the  hand  is  the  same,  right  or  left,  as  the  examin- 
ing hand.  The  position  of  the  foetus  may  also  be  determined 
from  that  of  the  arm  when  j)rolaj)sed  in  the  vagina  in  the  follow- 
ing way.  Draw  the  arm  gently  downward,  and  hold  it  in  a 
position  of  moderate  (not  excessive)  supination.  The  palm  of  the 
hand  will  then  look  towards  the  abdomen,  and  the  thumb  towards 
the  head  (see  Fig.  328).  Any  one  may  readily  test  the  appli- 
cability of  this  rule  by  stretching  out  his  own  hand  in  a  position  of 
supination. 

In  cases  where  the  anterior  or  the  posterior  surfaces  of  the 
trunk  present,  considerable  difficulty  may  be  met  with  in  coming  to 
a  correct  diagnosis,  and  in  all  doubtful  cases  an  anaesthetic  should 
be  administered,  the  whole  hand  introduced  with  great  care,  and 
a  certain  diagnosis  of  the  position  made. 

Prognosis. — The  prognosis  will  depend  upon  the  stage  at  which 
the  malposition  is  detected  and  the  skill  of  the  treatment. 
Churchill  estimated  the  mortality  of  the  mothers  as  being  as  high 
as  1  in  9,  and  that  of  the  children  as  1  in  2.  In  the  Guy's 
Hospital  Lying-in  Charity,  in  49,588  births,  there  were  140  shoulder 
or  transverse  presentations,  and  among  these  three  deaths,  two 
from  septicaemia,  one  from  rupture  of  the  uterus  before  assistance 
arrived.  Seventy  per  cent,  of  the  children  were  still-born,  includ- 
ing the  premature  children. 

In  transverse  presentations  treated  skilfully  the  maternal 
mortality  should  not  exceed  2  to  3  per  cent.,  while  that  of  the  children 
will  vary  between  10  and  30  per  cent. 

Natural  Terminations. — Although,  in  the  majority  of  cases, 
it  is  impossible  for  delivery  to  take  place  by  the  natural  forces,  yet 
to  this  rule  there  are  the  following  exceptions. 

Spontaneous  Rectification. — A  change  by  which  the  oblique 
j)Osition  of  the  foetus  is  converted  into  a  normal  one,  with  the 
head  presenting,  is  common  during  pregnancy,  and  may  occur 
even  during  labour.  As  a  general  rule,  but  not  invariably,  it  is 
necessary  for  its  occurrence  that  the  membranes  should  remain 
unbroken.  The  force  which  brings  the  head  towards  the  uterine 
axis  is  the  effect  of  the  contraction  of  the  circular  muscular  fibres. 
It  has  already  been  explained  that  the  uterus,  in  contracting,  no 


Labour  Obstructed  by  Anomalies  of  Ovum.     669 

longer  acts  like  a  shapeless  bag,  but  tends  to  assume  its  own 
pear-shaped  form ;  and  the  relatively  great  strength  of  the  con- 
traction of  the  circular  fibres  is  shown  by  the  fact  that  normally 
the  foetal  axis  is  lengthened,  not  shortened,  during  the  pains  (see 
p.  233).  Spontaneous  rectification  is  promoted  if  the  patient 
lies  on  the  side  opposite  to  that  towards  which  the  breech  is  deflected. 
For  then  the  breech  gravitates  towards  the  middle  line  ;  and  there- 
fore tends  to  bring  the  opposite  fcetal  pole — the  head,  also  towards 
the  middle  line.  Eectification  is  more  likely  to  happen  with  a 
living  child,  for  then  the  foetal  axis  has  greater  tonicity,  and  also 
the  movements  of  the  child  promote  adaptation.  The  relative 
frequency  of  spontaneous  rectification  cannot  be  estimated,  for  it 
may  often  have  occurred  in  the  first  stage  of  labour,  before  an 
examination  is  made.  In  the  Guy's  Charity,  out  of  77  cases  of 
shoulder  and  transverse  presentations  in  the  twelve  years  1863 — 
1875,  spontaneous  rectification  occurred  in  two,  after  rupture  of 
the  membranes  and  prolapse  of  the  arm,  the  head  coming  down 
by  the  side  of  the  arm,  and  the  child  being  expelled  without 
assistance. 

Spontaneous  Version. — In  spontaneous  version  the  long  axis  of 
the  foetus  is  not  brought  into  coincidence  with  the  uterine  axis  by 
the  shortest  way,  but  is  changed  into  a  nearly  reversed  position. 
The  breech  is  brought  down  towards  the  mother's  pelvis,  the 
shoulder  recedes  in  the  direction  of  the  head.  Eventually  the  head 
ascends  towards  the  fundus,  the  breech  becomes  the  presenting  part, 
and  the  case  is  terminated  like  one  of  pelvic  presentation.  Unlike 
spontaneous  rectification,  spontaneous  version  generally  occurs 
aftei'  the  rupture  of  the  membranes.  As  a  rule,  however,  it 
implies  that  the  shoulder  has  not  descended  very  low  into  the 
pelvis,  and  that  the  uterus  has  not  closed  so  tightly  round  the 
child  as  to  prevent  its  having  a  fair  mobility.  In  some  recorded 
cases,  however,  it  has  occurred  several  hours  after  rupture  of  the 
membranes. 

Spontaneous  version  is  not  so  easily  explained  as  spontaneous 
rectification,  for  the  usual  forces  of  adaptation  would  tend  to  pro- 
duce the  latter  change  only.  For  its  production  a  vigorous  but 
unequal  contraction  of  the  uterus  appears  to  be  the  essential. 
The  pressure  of  the  breech  stimulates  that  part  of  the  uterus  which 
covers  it,  especially  the  longitudinal  fibres,  to  contract  powerfully. 
The  breech  is  thus  forced  down  towards  the  pelvis,  and  at  the  same 
time  a  comparative  laxity  of  the  part  of  the  uterus  covering  the 
head  allows  the  head  to  rise,  and  the  presenting  shoulder  to  move 
in  the  direction  of  the  head.     As  soon  as  the  head  has  once  risen 


670 


The  Practice  of   Midwifery. 


above  the  level  of  the  breech,  the  usual  forces  of  adaptation  will 
tend  to  complete  the  version,  to  bring  the  axis  of  the  foetus  into 
coincidence  with  that  of  the  uterus,  and  to  make  the  breech  the 
presenting  part.  It  is  clear  that,  for  the  descent  of  the  breech  to 
cause  ascent  of  the  head,  the  axis  of  the  foetus  must  have  a 
certain  degree  of  tonicity.  Hence  as  a  rule  spontaneous  version 
takes  place  with  a  living  child  only.  It  is  possible  also  that  the 
movements  of  the  legs  may  have  something  to  do  in  evoking  the 
powerful  unequal  contraction  which  causes  descent  of  the  breech. 
By  some  authorities,  what  has  been  called  spontaneous  rectification 
is  included  as  a  variety  under  the  title  of  spontaneous  version,  but 

the  mechanism  of  the  two  pro- 
cesses is  opposite  in  character. 
In  the  Guy's  Hospital  Charity 
spontaneous  version  occurred 
in  4  cases  out  of  77,  living 
children  being  born  by  the 
breech. 

Spontaneous  Evolution.  —  In 
spontaneous  evolution  the  head 
remains  fixed  in  its  original 
position  without  elevation,  and 
a  rotation  of  the  foetus  takes 
place  about  the  point  where 
the  neck  is  jammed  against  the 
pubes,  aided  by  a  doubling  up 
of  the  body.  The  presenting 
arm  with  the  shoulder  is  first 
Fig.  329.-Commencemeut  of  spontaneous      ^y.[^Q^   deeply    into   the    pelvis. 

Then  more  and  more  of  the 
thorax  is  driven  down  beside  and  below  the  shoulder,  the  body 
becoming  doubled  upon  itself.  Some  rotation  of  the  longest 
diameter  of  the  doubled  foetus  into  the  antero-posterior  diameter 
of  the  pelvis  occurs  at  this  time  (Fig.  329),  the  prolapsed  arm 
coming  under  the  pubic  arch,  the  breech  into  the  hollow  of  the 
sacrum,  the  head  remaining  above  the  symphysis  pubis.  The 
side  presents  first  at  the  vulva  behind  the  prolapsed  arm,  then, 
the  shoulder  remaining  fixed,  the  breech  is  forced  lower  and 
lower  until  it  is  expelled,  followed  by  the  legs  (Fig.  331,  p.  672). 
Then  comes  the  thorax  with  prolapsed  arm,  and  finally  the  head, 
with  the  upper  arm  generally  lying  behind  it  (Fig.  332,  p.  672), 
For  spontaneous  evolution  to  be  j)ossible  the  child  must  be 
premature,  or   moderately  small  relatively  to  the  pelvis,  and  the 


Labour  Obstructed  by  Anomalies  of  Ovum.     671 


pains  vigorous.  While  spontaneous  version  generally  requires 
the  child  to  be  alive,  in  spontaneous  evolution  it  is  almost 
invariably  dead,  first  because  the  doubling  up  of  the  body  is 
greatly  facilitated  by  the  loss  of  tonicity  which  follows  its  death, 
and  secondly  because  the  child  could  hardly  survive  in  such 
a  position  the  enormous  pressure  required  to  cause  the  doubling 
up  and  expulsion.  Out  of  77 
cases  in  Guy's  Hospital 
Charity,  spontaneous  evolu- 
tion occurred  in  6.  Three 
of  the  children  were  prema- 
ture, two  were  twin  children, 
and  one  was  decomposed. 
In  two  other  cases  spon- 
taneous evolution  appeared 
to  have  commenced,  and 
was  completed  by  artificial 
extraction.  The  eight  chil- 
dren were  all  still-born.  It 
is,  of  course,  possible  that 
evolution  might  eventually 
occur  in  a  larger  proportion 
of  cases,  if  version  were  not 
performed. 

Spontaneous  evolution 
may  be  arrested,  or  the 
patient  may  die  from  exhaus- 
tion before  it  is  completed, 
as  in  the  case  shown  in 
Fig.  330.  Even  after  spon- 
taneous evolution  living  chil- 
dren are  occasionally  born. 
Thus  Diclcshoorn^  collected 
16  cases  from  the  literature, 
including  one  of  his  own  in  which  the  child  weighed  2,880 
grammes,  or  about  6  lb.  5  oz.  The  majority  of  the  children, 
however,  were  poorly  developed,  and  soon  died. 

S2>ontaneoiis  Expiihion,  or  evolutio  corpore  conduplicato. — This  is 
a  much  rarer  event  than  the  ordinary  spontaneous  evolution,  and 
requires  a  still  greater  capacity  of  the  pelvis  in  proportion  to  the 


Fig.    330. — Spontaneous    evolution    arrested. 
(From  a  frozen  section.  Chiara.^) 


1  Dickshooni,  Ned.  Tijdschr.  voor  Geneeskunde,  1902,  Bd.  2,  No.  12. 

2  Chiara,  La  Kvohv/Aom  spontanea  sorpresa  in  atto  mediante  congelazione,  Milan, 

1878. 


672 


The  Practice  of   Midwifery. 


size  of  the  fcetus.  The  capacity  is,  however,  required  only  in 
one  direction,  and  hence  a  contracted  conjugate  diameter  is  not 
necessarily  an  absolute  obstacle.  The  mechanism  is  similar  to 
that  of  spontaneous  evolution  up  to  the  stage  at  which  the  doubled 
side  has  descended  into  the  pelvis,  and  the  head  is  doubled  back 
upon  the  abdomen  (Fig.  330,  p.  671).  Then,  instead  of  remaining 
above  the  brim,  the  head  enters  the  pelvis,  pressed  deeply  into  the 
abdomen,  and  the  two  pass  together  (Fig.  333,  p.  673).  The 
presenting  shoulder  emerges,  following  the  arm,  then  head  and 
abdomen  together,  the  head  in  advance  of  the  breech,  and  finally 


Fig.  331. — Further  progress   of 
spontaneous  evolution. 


Fig.  332. 


-Termination  of  spontaneous 
evolution. 


the  legs.  This  kind  of  evolution  is  promoted  by  traction  upon 
the  arm,  the  presenting  shoulder  here  coming  in  advance.  It 
occurs  only  with  a  dead  fcetus,  and  generally  one  either  premature 
or  macerated.  No  instance  of  it  occurred  in  23,811  births  in  the 
Guy's  Hospital  Charity.  In  the  case  of  abortions,  before  the  child 
is  viable,  it  is  not  so  uncommon. 

Termination  of  Neglected  Cases. — After  the  rupture  of  the  mem- 
branes, nearly  the  whole  of  the  liquor  amnii  soon  drains  away,  the 
presenting  part  not  filling  up  the  os  closely.  The  uterus  then 
contracts  closely  around  the  foetus.  Pains  continuing,  provided 
that  the  case  is  not  terminated  in  any  of  the  ways  already  described, 
retraction  of  the  contractile  portions  of   the   uterus   occurs    (see 


Labour  Obstructed  by  Anomalies  of  Ovum.     673 


p.  628),  associated  with  great  stretching  of  the  cervix  and  lower 

distensible  zone  of  the  uterine  body.     This  is  apt  to  lead  to  rupture 

in  the  thinner  portions  of  the  uterus,  or  in  the  vagina.    Spontaneous 

rupture  occurs  very  infrequently  in  these  cases,  about  once  in  300 

instances,   but   rupture  of  the   uterus,  the  result   of   attempts  at 

version,  is  very  liable   to  occur  in  transverse  presentations.^     If 

rupture  does  not  take  place,  the  uterus  eventually  passes  into  the 

state   of    tetanic    contraction, 

and  the  other  grave  symptoms 

of  obstructed  labour  supervene 

(see    p.    623),      The    patient 

finally  sinks  from  exhaustion, 

or,  if   the  uterus  is  inactive, 

from     peritonitis    and    septic 

absorption  after  the  death  of 

the  foetus.     In  some  instances 

decomposition    occurs   in   the 

contents   of   the   uterus    after 

rupture    of    the    membranes, 

with    the    development    of    a 

physometra. 

Treatment. — If  the  patient 
is  seen,  as  she  should  be,  about 
six  weeks  before  full  term  in 
all  cases  of  pregnancy,  it  will 
be  often  possible  to  correct  by 
external  manipulation  an 
oblique  presentation.  When 
she  is  seen  for  the  first  time 
after  the  onset  of  labour  the 
treatment  consists  in  rectifica- 
tion of  the  position  of  the  foetus 

by  version,  so  as  to  bring  either  the  head  or  the  pelvis  to  present. 
This  will  be  described  in  full  in  Chapter  XXXIV.  The  version 
is  to  be  carried  out  in  the  mode  which  implies  the  least  possible 
interference ;  if  possible,  before  the  rupture  of  the  membranes,  by 
external  manipulation  only ;  otherwise  by  bipolar  version ;  if  this 
also  fails,  as  will  generally  be  the  case  when  the  membranes  have 
been  ruptured  some  time,  by  the  ordinary  internal  version.  In  all 
cases  after  version  the  birth  of  the  child  should  be  left  to   the 

1  Ivanotf,  Annalcs  de  Gyn6cologic,  1904,  pp.  44'.»,  513,   58!) ;  Merz,  Arch.  f.  Gyn., 
1894,  Bfl.  45,  Hft.  2,  p.  383  ;  Kleinwachter,  Arch.  f.  Gyn.,  1871,  Bd.  2,  Hft.  1,  p.  111. 

M.  43 


Fig.  833. — Spontaneous  expulsion. 
Kleinwachter.) 


(After 


674 


The   Practice  of   Midwifery. 


natural  forces  unless  there  is  some  definite  indication  for  rapid 
delivery. 

Decapitation. — It  is  only  in  very  rare  and  long-neglected  cases 
that  version  will  fail,  in  moderately  skilful  hands,  if  chloroform  be 
given  to  the  full  surgical  degree,  and  if  the  small  blunt  hook  or 
noose  be  employed,  if  required,  to  make  traction  upon  the  knee 
or  foot  (see  Chapter  XXXIV.).     I  have  never  met  with  a  case  in 


Fig.  334.— Decapitating 
hook,  with  serrated 
edge. 


Fig.  335. — Decapitation. 


which  the  knee  or  foot  could  not  be  reached.  But  it  does  some- 
times happen,  when  the  uterus  is  very  firmly  contracted  around 
the  child,  as,  for  instance,  when  the  liquor  amnii  has  escaped  for 
several  days,  that  the  foetus  cannot  be  got  to  revolve  by  any  safe 
degree  of  traction  upon  the  leg.  It  may  even  happen,  with  a 
decomposed  foetus,  that  the  leg  may  separate,  and  come  away.  By 
far  the  best  resource,  if  the  neck  can  be  reached,  is  then  decapita- 
tion. Also,  if  there  is  strong  evidence  that  the  child  is  dead, 
decapitation  may  be  performed  in  preference  to  exerting  great  force 
in  attempting  to  effect  version,  lest  rupture  of  the  uterus  should 


Labour  Obstructed  by  Anomalies  of  Ovum.     675 

result.  More  especially,  if  the  shoulder  is  driven  down  low  in  the 
vagina,  the  arm  protruding  externally,  no  attempt  should  be  made 
at  version,  for  the  child  is  then  certain  to  be  dead,  and  version 
would  be  dangerous.  The  best  instrument  to  decapitate  with  is  a 
semi-circular  hook,  with  a  serrated  edge  (Fig.  334).  Other  modes 
of  operating  have  been  recommended,  such  as  cutting  upwards 
with  blunt-pointed  scissors,  the  neck  being  fixed  with  a  blunt 
hook,  or  the  use  of  a  sharp  hook,  semi-circular  or  sickle-shaped. 
Scissors  are  apt  to  wound  the  soft  parts,  or  operator's  fingers,  and 
the  operation  with  them  is  tedious  and  difficult.  A  sharp  hook  is 
apt  to  become  blunted  against  the  vertebrae,  and  then  fail  to  divide 
the  spinal  column.  With  a  serrated  hook  delivery  can  always  be 
effected  in  a  few  minutes,  if  the  hook  is  once  placed  over  the  neck. 
It  is  essential,  however,  that  the  teeth  should  be  sufficiently  fine, 
and  slanted  in  one  direction  like  those  of  a  saw. 

The  following,  then,  is  the  method  to  be  adopted  in  decapita- 
tions : — Bring  the  shoulder  as  low  as  possible  by  careful  traction 
upon  the  prolapsed  arm.  The  neck  can  then  generally  be  reached 
by  the  left  hand  passed  into  the  vagina.  Carry  the  decapitator, 
protected  by  the  flexor  surface  of  the  fingers,  up  in  front  of  the 
neck,  passing  it  along  the  arm,  the  point  directed  toward  the  head, 
until  it  reaches  the  level  of  the  neck.  Then  turn  its  point  backward, 
and  pass  it  over  the  neck  ;  make  quite  certain  that  it  is  in  right 
position  by  feeling  the  point  behind  the  neck  (Fig.  835).  Now  draw 
the  decapitator  firmly  downward,  at  the  same  time  that  its  handle 
is  swayed  backward  and  forward  as  widely  as  the  vaginal  outlet 
will  allow.  In  this  way  the  neck  is  quickly  cut  through.  As  soon 
as  the  vertebrae  are  divided,  note  from  time  to  time  with  the  fingers 
the  direction  the  plane  of  section  is  taking,  and  see  that  it  does  not 
slope  too  much  backward  into  the  shoulder,  instead  of  cutting  off 
the  head.  It  may  be  necessary  to  incline  the  handle  of  the  decapi- 
tator somewhat  in  the  direction  of  the  head,  if  this  lies  very  high 
up.  Take  care  that  the  last  piece  of  tissue  is  not  divided  too 
quickly,  lest  the  decapitator  injure  the  maternal  soft  parts  in  its 
sudden  release. 

While  the  tissues  of  the  neck  are  being  sawn  through  one  or 
two  fingers  of  the  left  hand  should  be  placed  upon  the  under- 
aspect  of  the  neck,  so  as  to  hold  it  firmly  in  position,  and  by 
making  counter-pressure  minimise  the  risk  of  rupturing  the  lower 
uterine  segment  during  the  operation. 

The  reason  why  the  point  of  the  decapitator  should  be  turned 
backward  is  to  avoid  injury  to  the  bladder.  Owing  to  the  direction 
of  the  vulval  outlet,  the  handle  must  be  inclined  forward.     There 

43—2 


676  The  Practice  of   Midwifery. 

is  therefore  less  risk  of  injuring  the  rectum  by  cutting  downward 
and  forward  than  there  would  be  of  injuring  the  bladder,  if  the 
point  were  turned  toward  the  pubes, 

By  decapitation,  the  obstructing  wedge  is  broken  up,  and  the 
body  of  the  foetus  is  easily  withdrawn  by  traction  upon  the  pro- 
lapsed arm.  It  remains  only  to  deal  with  the  head.  If  the  uterus 
then  contracts  strongly,  the  head  may  be  dehvered  spontaneously 
or  by  expression.  The  uterus,  however,  acts  at  a  disadvantage 
upon  so  small  a  body,  and  will  probably  be  in  a  state  of  continuous 
action  from  protracted  labour ;  otherwise  decapitation  would  not  have 
been  necessary.  In  this  case  it  will  be  necessary  to  deliver  the 
head  artificially.  If,  as  is  usually  the  case,  there  are  no  projecting 
vertebrse  at  the  stump  of  the  neck,  the  best  way  is  to  hook  the 
finger  in  the  mouth,  or  the  thumb  in  the  mouth  and  the  fingers 
over  the  base  of  the  skull,  and  bring  the  head  down  in  face  pre- 
sentation. If  there  is  much  resistance  to  its  passage,  a  small 
blunt  hook  or  crochet  may  be  substituted  for  the  finger.  If,  how- 
ever, there  is  a  sharp  or  rough  projection  of  the  vertebrae  at  the 
neck,  this  would  be  turned  sideways,  and  might  cause  injury  to  the 
cervix  or  vagina,  if  the  head  were  brought  down  in  face  presenta- 
tion. It  is  then  better,  if  possible,  to  seize  the  stump  of  the  neck 
with  craniotomy  forceps  of  a  simple  form  and  bring  the  head  down 
like  an  aftercoming  head.  Forceps  may  also  be  employed  for 
extraction.  In  the  case  of  pelvic  contraction  it  may  be  necessary 
to  perforate  the  head,  while  counter-pressure  is  made  by  an  assistant 
over  the  uterus,  and  afterwards  extract  it  with  the  cephalotribe  or 
by  other  means  (see  Chapter  XXXV.). 

Embryotomy. — Version  having  been  found  impossible,  the  only 
ease  in  which  the  neck  cannot  be  reached  for  decapitation  is  that 
in  which  there  is  already  a  tendency  to  spontaneous  evolution,  the 
shoulder  and  side  descending  very  low  into  the  pelvis  and  filling  it 
up,  while  the  neck  remains  high  up  (Fig.  330,  p.  671).  In  this 
case  the  best  plan  is  to  assist  evolution,  either  by  hooking  the 
fingers  over  the  breech,  if  evolution  has  proceeded  far  enough  for 
this  to  be  possible,  or,  if  not,  by  first  inserting  a  small  blunt  hook 
or  crochet  into  the  thorax  or  abdomen,  and  drawing  these  down  in 
succession.  No  space  is  to  be  gained  by  evacuation  of  the  contents 
of  the  thorax,  and  but  little  in  general  by  the  evacuation  of  those  of 
the  abdomen.  It  is  of  little  use,  therefore,  to  jperforate  the  thorax ; 
but  the  abdomen  may  be  perforated  with  advantage,  if  delivery  is 
found  difiicult,  especially  if  it  has  become  at  all  distended  after  the 
death  and  decomposition  of  the  foetus.  If  the  evolution  cannot  be 
otherwise  completed,  the  spinal  column  can  be  divided  with  strong 


Labour  Obstructed  by  Anomalies  of  Ovum.     677 

scissors,  and  the  two  halves  of  the  trunk  extracted  separately  by 
means  of  the  cephalotribe. 

The  same  operation  of  dividing  the  spinal  column,  or  sjyondy- 
lotomy,  has  been  recommended  by  Prof.  A.  R.  Simpson,  as  an 
alternative  to  decapitation.  It  is  stated  that  version  is  thereby 
rendered  practicable.  The  operation  is,  however,  not  nearly  so 
easy  as  decapitation  performed  in  the  method  above  described, 
nor  is  the  subsequent  delivery  so  easy  as  that  after  decapitation. 


Fig-.  336. — Presentation  of  head  and  hand.     (Braune's  Atlas  of  Topographical 
Anatomy,  PI.  XXX.) 

Pkesentation  of  Hand  or  Arm  with  Head. — Presentations 
of  either  hand  or  arm  with  head,  or  the  prolapse  of  either  by  the 
side  of  the  head,  like  the  descent  of  the  knee  or  foot  in  pelvic 
presentation,  imply  a  departure  from  the  normal  attitude  of  the 
foetus.  They  are,  therefore,  promoted  by  the  death  of  the  foetus, 
which  destroys  the  tonicity  of  muscle  by  which  it  maintains  its 
usual  attitude,  and  also  by  its  immaturity.  Other  causes  are 
excess  of  liquor  amnii ;  smallness  of  the  head  in  reference  to  the 
pelvis,  allowing  room  for  the  hand  by  the  side  of  the  head ;  and 
irregularity  of   the  pelvis,  especially  contraction  of  the  conjugate 


678 


The  Practice  of   Midwifery. 


diameter,  which  prevents  the  head  from  accm-ately  fitting  into 
and  fining  up  the  pelvic  brim.  The  hand  may  either  be  felt  at 
the  side  of  the  head  before  ruptm'e  of  the  membranes,  or  it  may 
be  swept  down  in  the  sudden  escape  of  a  large  amount  of  liquor 
amnii.  Sometimes,  again,  the  hand  does  not  at  first  present  with 
the  head,  but  is  expressed  by  the  side  of  it,  when  there  are  strong 
pains,  and  the   head   does   not   fill   up   the   brim   on   account   of 

deformity.      This    is    most    likely   to 
happen  when  the  child  is  dead. 

Obstruction  is  only  produced  when 
there  is  not  room  enough  for  the  hand 
and  head  together.  It  is  more  likely 
to  occur  the  more  the  hand  is  in 
advance  of  the  head.  If  the  hand  only 
just  appears  by  the  side,  it  frequently 
remains  behind  as  labour  advances, 
and  the  head  is  born  first.  If,  how- 
ever, the  arm  is  far  in  advance,  there 
is  danger  that  the  head  may  be  deflected 
into  the  iliac  fossa,  and  the  shoulder 
descend.  If  the  hand  is  at  the  side  of 
the  pelvis,  it  is  less  likely  to  obstruct 
that  when  it  lies  in  front,  and  so 
reduces  the  space  in  the  conjugate  dia- 
meter available  for  the  head.  In  the 
Guy's  Hospital  Lying-in  Charity,  out 
of  22,980  births,  there  was  a  presenta- 
tion of  hand  with  head  in  54  cases, 
or  2-2  per  1,000,  or  1  in  425.  14-8 
per  cent,  of  the  children,  or  1  in  6*7, 
were  still-born. 

Fig.  337. — Dorsal  displacement 
of  the  arm. 

Treatment. — Before  the  rupture  of 
the  membranes,  an  attempt  may  be  made  to  push  back  the  hand  or 
arm  through  the  membranes,  while  the  other  hand,  used  externally, 
fixes  the  head  in  the  brim.  The  patient  should  lie  on  the  side 
opposite  to  that  on  which  the  hand  is  prolapsed,  in  order  to  counter- 
act any  tendency  to  deviation  of  the  head  toward  the  iliac  fossa. 
The  attempt  at  reposition  of  the  hand  may  be  repeated  on  rupture 
of  the  membranes,  if  it  has  not  succeeded  before.  If  it  still  fails,  and 
the  hand  merely  descends  by  the  side  of  the  head,  the  case  should 
be  left  to  nature,  unless  symptoms  of  protracted  labour  appear. 
Delivery  should  then  be  accelerated  by  forceps,  and  the  hand  will 


"Labour  Obstructed  by  Anomalies  of  Ovum.     679 


frequently  fall  behind,  being  retarded  by  friction.  In  applying 
forceps  care  must  be  taken  not  to  include  the  hand  between  the 
blades.  If  the  arm  descends  much  in  advance  of  the  head,  and 
the  head  remains  high  in  the  pelvis,  it  is  better  to  perform  version 
rather  than  apply  forceps.  Version  should  also  be  performed  in 
any  case  in  which  the  head  is  above  the  brim,  and  contraction  of 
the  conjugate  diameter  is  found  to  a  degree  which  is  likely  to 
render  the  passage  of  the  head  difficult  (see  Chapter  XXIX.). 

DoKSAL  Displacement  of  the  Akm. — Sometimes  the  arm  becomes 
displaced  so  that  the  forearm  lies  transversely  across  the  back  of 
the  neck,  and  forms  a  bar  or  ridge  which  may  catch  upon  the 
pelvic  brim,  and  impede  the 
advance  of  the  fcetus  (Fig. 
337).  This  condition  will 
naturally  escape  diagnosis 
unless  the  hand  is  carried 
up  past  the  head  to  explore, 
a  proceeding  which  will  gene- 
rally require  full  administra- 
tion of  an  anaesthetic.  Such 
an  exploration  will  generally 
have  been  indicated  by  failure 
to  bring  down  the  head  with 
forceps,  while  there  is  not 
sufficient  disproportion  be- 
tween the  head  and  pelvis  to 
account  for  the  difficulty. 

Treatment.  —  Extraction 
by  forceps  having,  by  supposi- 
tion, failed,  the  best  treatment  will  generally  be  version.      Sir  J. 
Simpson,  who  first  described  the  condition,  advised  bringing  down  the 
arm,  so  as  to  convert  the  case  into  one  of  hand  and  arm  presentation. 

Presentation  of  Hands  and  Feet  together. — Presentation  of 
hands  with  feet  implies  that  the  position  of  the  fcetus  is  more  or 
less  oblique  or  transverse,  and  that  legs  or  arms  are  extended 
(Fig.  338).  Most  frequently  the  breech  is  lying  lower  than  the 
head,  and  the  arms  are  extended. 

Treatment. — Before  rupture  of  the  membranes,  the  axis  of  the 
foetus  should  be  brought  into  coincidence  with  that  of  the  uterus  by 
external  manipulation,  if  possible,  so  as  to  produce  either  a  head  or 
breech  presentation.     If  this  fails,  as  soon  as  the  os  is  fairly  dilated, 


Fig.  338. 


-Presentation  of  a  hand  and  foot 
with  funis. 


68o 


The  Practice  of   Midwifery. 


one  foot  should  be  brought  down,  and  traction  made  upon  it  until 
the  half-breech  fully  occupies  the  os,  the  hands  have  receded,  and 
the  head  occupies  the  summit  of  the  uterus. 

Presentation  of  Foot  with  Head. — Presentation  of  a  foot,  or  of 
both  feet,  with  the  head  is  very  much  rarer  than  that  of  hand  with 
head.  It  imj)lies  a  doubled-up  condition  of  the  foetus  as  well  as 
extension  of  the  leg.  Accordingly,  it  is  chiefly  found  with  pre- 
mature and  dead  children.     If  it  happens  with  a  living  child,  it 


Fig.  339. — Locked  twins. 

may  be  due  to  the  foot  having  presented  in  the  first  instance,  the 
axis  of  the  child  being  somewhat  oblique,  and  to  the  head  having 
been  brought  down  with  a  rush  of  liquor  amnii  escaping  suddenly. 
I  have  known  this  occur  when  the  foot  has  been  seized,  in  order  to 
bring  it  down  artificially,  but  not  drawn  down  quickly  enough  on 
the  rupture  of  the  membranes.  A  similar  condition  may  be 
produced  by  an  attempt  at  version,  when  the  foot  has  been  brought 
down,  but  the  head  will  not  recede. 

Treatment. ^If  the  membranes  are  unruptured,  or  shortly  after 
their  rupture,  the  foot  may  be  pushed  up  above  the  head  if  possible. 
Much  time  should  not  be  expended  upon  this  attempt  after  rupture 


Labour  Obstructed  by  Anomalies  of  Ovum.     68 1 

of  the  membranes,  especially  if  the  child  is  living,  since  it  is  likely 
soon  to  perish  from  pressure  in  its  doubled-up  attitude.  If  the 
attempt  does  not  succeed,  traction  should  be  made  upon  the  foot 
until  the  half -breech  is  brought  into  the  os  and  the  head  recedes. 
If  this  proves  difficult,  a  noose  of  tape  should  be  placed  round  the 
foot  for  traction,  so  as  to  leave  the  pelvis  free  for  counter-pressure 
upon  the  head  with  the  other  hand.  Traction  and  pressure  may 
then  be  tried  simultaneously,  or,  if  this  does  not  succeed,  alternately, 
until  the  fcetus  revolves.  If  this  failed,  perforation  of  the  head 
would  be  the  only  remedy,  but  this  would  hardly  ever  be  necessary. 
Before  making  traction  on  the  foot,  the  physician  should  make  sure, 
by  abdominal  palpation,  that  head  and  foot  belong  to  the  same 
child,  not  to  twins :  since,  if  they  belonged  to  twins,  the  head 
should  be  delivered  first,  and  the  other  treatment  might  lead  to  the 
twins  becoming  locked. 

Locked  Twins. — Obstruction  to  labour  from  locking  of  twins  is 
rare,  but  is  apt  to  be  serious  when  it  does  occur,  and  especially 
fatal  to  the  children.  The  children  are  in  separate  membranes  in 
the  great  majority  of  cases  of  twin  pregnancy  (see  p.  366),  and  then 
the  membranes  of  the  second  child  prevent  its  interfering  with  the 
first.  Even  if  the  twins  are  in  a  common  amnion  the  second 
child  as  a  rule  glides  out  of  the  way  as  the  first  enters  the  pelvis. 
It  is  only  when  the  heads  are  small  relatively  to  the  pelvis 
that  they  are  apt  both  to  enter  the  pelvis  together,  and  so  become 
locked. 

First  Variety. — The  first  way  in  which  twins  can  become  locked 
is  when  both  present  by  the  head.  The  second  head  may  then  be 
pressed  in  between  the  head  and  thorax  of  the  first  child,  and  so 
partially  enter  the  pelvis  with  the  thorax  and  there  become  arrested. 
The  first  child  is  in  greatest  danger,  for  the  funis  may  be  compressed 
as  well  as  the  thorax,  if  the  two  have  advanced  far  into  the  j)elvis. 
According  to  Eeimann,^  in  six  cases,  five  of  the  first  children  were 
still-born,  and  four  of  the  last. 

Treatment. — The  condition  will  generally  only  be  discovered  after 
birth  of  the  first  head,  or  an  obstruction  being  met  with  to  its 
extraction  by  forceps.  The  second  head  should  be  pushed  up  out 
of  the  way  if  possible.  If  this  cannot  be  done,  delivery  must  be 
effected  by  traction  on  the  first  child.  Perforation  of  the  second 
head  will  rarely  be  necessary,  and  should  not  be  carried  out,  unless 
the  second  child  is  certainly  dead,  before  a  further  attempt  has  been 

1   Arcliiv.  f.  Gyniik.,  1871,  Vol.  II.,  pp.  99—101. 


682  The  Practice  of   Midwifery. 

made  to  overcome  the  difficulty  by  perforating  the  head  of  the 
first  child. 

Second  Variety. — The  second  variety  of  locked  twins  arises 
when  the  first  child  presents  by  the  pelvis  and  the  second  by  the 
head.  The  head  of  the  second  child  may  then  enter,  or  partially 
enter,  the  pelvis,  pressed  in  between  the  head  and  thorax  of  the 
first  (Fig.  339).  The  first  child  then  quickly  perishes,  its  funis 
being  exposed  to  pressure.  If  space  is  ample  both  children  may 
IDass  the  pelvis  together  in  this  position.  In  some  cases  the  whole 
of  the  second  child  has  been  spontaneously  expelled  before  the 
delivery  of  the  first  head.  According  to  Keimann,  23  out  of  26 
of  the  first  children,  but  only  10  out  of  29  of  the  second  children, 
in  such  cases  were  still-born. 

Treatment. — If  the  heads  are  still  high  in  the  pelvis,  it  may  be 
possible  to  push  up  the  lower  head  out  of  the  way  while  the  first 
child  is  delivered.  If  this  cannot  be  done,  the  head  of  the  first 
child,  lying  uppermost,  should  be  severed  with  the  serrated  hook 
(see  p.  674)  or  scissors.  The  body  of  the  first  child  is  then 
easily  delivered,  next  the  second  child,  and  finally  the  head  of 
the  first.  If  the  head  cannot  be  severed,  it  may  be  perforated, 
but  this  does  not  so  completely  overcome  the  difficulty.  This  is 
probably  better  treatment  than  attempting  to  deliver  the  second 
child  by  applying  forceps  to  its  head,  since  in  any  case  the  chances 
of  delivering  the  first  child  alive  are  very  small.  These  expedients 
failing,  there  remains  the  resource  of  perforating  the  lower  head, 
and  extracting  with  the  cephalotribe,  or  by  other  means,  but  this 
plan  involves  the  death  of  both  children.  When  the  obstruction 
is  due  to  the  locking  of  the  aftercoming  head  with  the  shoulder 
and  prolapsed  arm  of  the  second  child  the  best  treatment  will  be 
decapitation  of  the  first  child  and  the  delivery  of  the  second  by 
version. 

FCETAL    MONSTEOSITIES. 

Conjoined  Twins. — Conjoined  twins  are  extremely  rare,  com- 
pared with  the  total  number  of  deliveries,  but  a  considerable 
number  of  cases  altogether  have  been  recorded.  Conjoined  twins 
are  divided  by  Playfair  ^  into  the  four  following  classes,  including  all 
varieties  likely  to  cause  much  difficulty  in  delivery  : — 

A. — Thoracopagus.     Two  nearly  separate  bodies  united  in  front 
to  a  varying  extent,  by  the  thorax  or  abdomen. 

1  Playfair,  Trans.  Obst.  Soc.  London,  1867,  Vol.  VIII.   p.  300. 


Labour  Obstructed  by  Anomalies  of  Ovum.     683 

B. — IscHioPAGUs.  Two  nearly  separate  bodies  united  back  to 
back  by  the  sacrum  and  lower  part  of  the  spinal  column. 

C. — DicBPHALUs.  The  bodies  being  single  below,  but  the  heads 
separate. 

D. — Syncephalus.  The  bodies  separate  below,  but  the  heads 
fused  or  partially  united. 

Out  of  31  cases  collected  by  Play  fair,  spontaneous  delivery  took 
place  in  20. 

Class  A. — This  is  the  most  numerous,  including  19  cases  out  of 
31  (Fig.  340).  Both  children  present  by  the  feet  in  a  much  larger 
proportion  of  cases  than  normal  children.  Playfair  regards  this 
as  the  most  favourable  presentation,  and  recommends  version  in 
the  rare  cases  of  head  presentation,  in  which  a  diagnosis  can  be 
made  early  enough  to  allow  it.  The  bodies  generally  pass  the 
pelvis  parallel  to  each  other,  without  much  difficulty,  but  obstruc- 
tion may  arise  when  the  heads  enter  the  brim.  Owing  to  the 
bodies  being  inclined  forward  toward  the  pelvic  outlet,  the  posterior 
head  will  enter  the  brim  in  advance.  In  aiding  delivery  it  is 
important  to  bring  down  this  head  as  far  in  advance  of  the  other 
as  possible.  The  bodies  should  therefore  be  carried  as  far  forward 
as  possible,  and  traction  made  chiefly  upon  the  body  belonging 
to  the  posterior  head.  Force23S  may  be  applied  to  this  head,  if 
necessary,  or  it  might  be  requisite  to  perforate  it. 

"When  the  heads  present  spontaneous  delivery  may  occur  in  one 
of  two  ways.  In  the  first  and  more  common  the  head  of  the  first 
child  is  born  first,  and  advances  until  it  is  arrested  by  tension  upon 
the  band  or  surface  of  union.  Then  the  two  bodies  are  born 
together  by  a  kind  of  spontaneous  evolution,  the  body  of  the  first 
child  in  advance.  In  this  evolution,  the  second  head  remaining 
above  the  brim,  a  rotation  of  the  two  bodies,  accompanied  by  a 
doubling  up,  takes  place  around  the  point  where  the  neck  of  the 
second  child  rests  upon  the  pelvic  brim.  It  is  somewhat  analogous 
to  the  spontaneous  evolution  in  shoulder  presentations  (see  p.  670). 
Finally,  the  second  head  is  delivered. 

In  the  second  mode  of  delivery,  both  heads  are  in  the  pelvis 
together,  the  second  head  being  pressed  in  between  the  head  and 
thorax  of  the  first  child,  as  in  the  first  variety  of  locked  twins.  The 
lower  head  will  become  anterior  towards  the  pelvic  outlet.  For  this 
mode  of  delivery  it  is  essential  that  the  children  should  be  very 
small  in  proportion  to  the  pelvis. 

Treatment. — In  the  case  of  head  presentation  a  diagnosis  is  only 
likely  to  be  made  when  the  progress  of  the  first  child  is  arrested 
after   birth   of   the   head  or   in  the  pelvis,    and  for  this   purpose 


684 


The  Practice  of   Midwifery. 


complete  anaesthesia  and  the  mtroduction  of  the  hand  will  generally 
be  necessary.  Evolution  may  be  assisted  by  traction  upon  the 
conjoined  bodies,  or  bringing  down  the  feet  if  practicable.  In  case 
of  necessity  there  need  be  little  hesitation  to  divide  the  band  of 
union,  or  carry  out  any  other  form  of  embryotomy  which  appears 
to  be  indicated.  Cleidotomy  often  will  be  found  most  useful.^  If 
the  first  head  is  still  in  the  pelvis,  version  should  be  performed,  and 
all  four  feet  brought  down. 

Class  B.  comprises  three  cases  out  of  the  31.     The  children  in 


Fig.  340. — Thoracopagus  monster.    (Univ. 
Coll.  Hosp.  Med.  School  Mus.) 


Fig.  341. — Dicephalus  monster. 
(Meigs.;)  2 


these  were  delivered  spontaneously,  the  first  head  in  advance,  then 
the  bodies  by  evolution,  then  the  second  head.  Delivery  in  this  way 
is  easier  than  in  Class  A.,  because  the  junction  is  generally  lower 
down,  allowing  the  bodies  to  be  more  separated,  and  more  of  the 
body  of  the  first  child  to  be  born,  before  traction  comes  upon  the 
surface  of  the  union,  and  evolution  commences. 

Class  C.  comprises  seven  cases  out  of  the  31  (E'ig.  341).  In  two 
the  children  were  delivered  spontaneously.  The  usual  mechanism 
is  the  delivery  of  first  the  first  head,  then  the  body  by  evolution, 
then  the  second  head.     If  the  presentation  is  a  breech,  then  the 

1  Ballantyne,  Munro  Kerr's  Operative  Midwifery,  1908,  p.  121. 

2  Meigs,  The  Science  and  Art  of  Obstetrics.     1868. 


Labour  Obstructed  by  Anomalies  of  Ovum.     685 

single  body  is  usually  born  without  much  difficulty,  followed  by 
the  posterior  and  then  by  the  anterior  head. 

Treatment. — Evolution  should  be  assisted  by  traction  upon  the 
body,  or  by  bringing  down  the  feet,  if  possible,  after  the  birth  of 
the  first  head.  If  this  cannot  be  effected,  some  extra  space  may 
be  gained  by  evisceration.  If  the  first  head  is  arrested  within  the 
vagina,  its  removal  by  decapitation,  or  perforation,  may  be  necessary 
before  the  feet  can  be  brought  down. 

Class  D.  is  the  rarest,  comprising  only  two  cases  out  of  the  31 


Fig.  342. — Syncephalus monster.  (Univ. 
Coll.  Hosp.  Med.  School  Mus.) 


Fig.  34.S. — Anencephalus  monster.     (Univ. 
Coll.  Hosp.  Med.  School  Mus.) 


(Fig.  342).  The  enlarged  monstrous  head  is  the  part  most  likely  to 
cause  difficulty.  It  must  be  delivered,  if  necessary,  by  craniotomy. 
In  all  these  classes  the  prognosis  to  the  children  is  very  bad, 
since  they  are  often  premature,  and  subjected  to  pressure  in  a 
doubled  position.     The  results  to  the  mothers  have  been  favourable. 

Other  Forms  of  Monstrosity. — There  is  another  variety  of 
double  monster,  which  does  not  usually  cause  much  difficulty  in 
delivery,  namely,  tliat  in  which  there  is  partial  or  complete  doubling 
of  upper  or  lower  limbs,  generally  of  the  latter. 

Acardiac     Monsters. — The    production    of    an    acardiac   ace 
phalic  monster  out  of  one  of  twins,   when  the  umbilical  arteries 


686  The  Practice  of   Midwifery. 

communicate,  by  reversal  of  the  current  of  blood  in  the  weaker  child, 
has  already  been  described  (see  p.  369).  There  may  be  a  large 
sha]3eless  mass,  replacing  the  head  and  thorax,  formed  by  hyper- 
trophy of  a  low  form  of  cellular  tissue  and  oedema,  but  it  rarely 
causes  difficulty  in  delivery.  The  monster  generally  presents  by 
the  feet.  The  amorphous  variety  of  acardiac  monster,  in  which 
there  is  merely  a  shapeless  mass,  without  either  head  or  limbs,  has 
to  be  extracted  like  a  detached  head  after  the  birth  of  the  first 
twin. 


Anencephalic  Monsters. — -In  these  there  is  absence  of  the 
brain  and  vault  of  the  skull,  the  eyes  are  prominent,  and  the  face 
looks  upward.  The  neck  is  short,  the  shoulders  relatively  broad 
and  large.  This  form  of  monstrosity  has  been  supposed  to  originate 
from  hydrocephalus  at  a  very  early  stage  of  development,  followed 
by  rupture  and  disappearance  of  the  brain  substance.  Other 
authorities  deny  this  explanation.  If  the  head  presents,  it  generally 
does  so  by  the  face.  Pelvic  and  transverse  presentations  are 
common,  while  i^rolapse  of  the  cord  or  limbs  may  occur.  If  the 
head  presents  it  may  cause  difficulty  in  diagnosis.  The  nature  of 
the  case  will  be  discovered  by  recognising  the  features  of  the  face, 
not  surmounted  by  any  cranium,  and  feeling  the  sella  turcica  and 
other  projections  of  the  base  of  the  skull.  The  broad  shoulders 
may  cause  delay  in  delivery,  especially  when  these  follow  the  head, 
too  small  to  dilate  a  passage  for  them.  If  labour  is  protracted  from 
this  cause,  while  the  head  is  yet  high  in  the  pelvis,  version  should 
be  performed,  and  delivery  accelerated  by  traction,  or  cleidotomy 
may  be  practised. 

Extroversion  of  Viscera. — In  some  cases  a  large  portion  of  the 
viscera,  especially  the  liver  and  the  small  intestines,  lies  outside 
the  abdomen,  uncovered  by  skin,  and  covered  only  by  the  amnion. 
This  condition  is  sometimes  associated  with  shortness  of  the  funis, 
which  is  attached  to  the  extroverted  mass.  The  deformity  more 
often  causes  difficulty  in  diagnosis  of  the  presentation  than  difficulty 
in  labour.  The  fcetus  is  often  in  a  position  of  extension  or 
opisthotonos,  and  the  liver,  or  other  part  of  the  extroverted  mass, 
may  then  present.  The  liver  frequently  ruptures  during  delivery. 
It  may  at  first  be  mistaken  for  a  placenta  prgevia,  but  is  dis- 
tinguished from  it  by  the  absence  of  haemorrhage.  If  the  extroverted 
mass  presents,  version  should  be  performed,  as  in  other  cases  of 
transverse  presentation. 


Labour  Obstructed  by  Anomalies  of  Ovum.     687 

Excessive  Development  of  the  Fcetus. — Excessive  size  of  the 
foetus  is  rarely  so  extreme  as  to  cause  much  difficulty  in  a  perfectly 
normal  or  wide  pelvis.  Combined,  however,  with  slight  degrees 
of  narrowness  in  the  maternal  passages,  a  large  size  of  the  foetus  is 
one  of  the  commonest  causes  of  difficulty.  Thus  the  greater  size  of 
male  children,  and  firmer  ossification  of  their  cranial  bones,  are  the 
reasons  why  a  greater  proportion  of  males  is  still-born.  Excessive 
size  of  the  foetus  may  depend  in  part  upon  the  size  of  the  parents, 
and  is  likely  to  be  most  marked  in  relation  to  the  pelvis,  when  the 
father  is  very  large  in  proportion  to  the  mother.  The  size  of  the 
children  also  increases,  up  to  a  certain  point,  with  the  age  of  the 
mother  and  the  frequency  of  pregnancies  (see  p.  120).  In  some 
cases  excessive  size  of  the  foetus  is  due  to  post-maturity,  up  to  one 
month  or  even  more.  In  such  cases  very  serious  difficulty  may 
arise,  even  with  a  full-size  pelvis. 

Excessive  ossification  of  the  cranial  bones  is  recognised  by 
unusual  smallness  of  the  anterior  fontanelle,  and  the  unyielding 
feel  of  the  bones,  even  near  their  edges.  Combined  with  a  moderate 
disproportion  of  the  head  to  the  pelvis,  it  very  greatly  increases 
the  difficulty  of  delivery,  since  the  diminution  of  the  cranial 
diameters  by  moulding  is  rendered  difficult. 

Treatment. — Protracted  labour  from  excessive  size  of  the  foetus 
is  to  be  treated  in  the  same  way  as  when  due  to  equable  contraction 
of  the  pelvis.  The  size  of  the  head  cannot  be  exactly  measured, 
but  can  only  be  estimated  generally  from  the  comparatively  slight 
curvature  of  the  cranial  bones,  the  length  of  the  sagittal  suture, 
and  the  degree  to  which  the  head  fills  up  the  pelvic  space,  or  its 
failure  to  enter  the  brim.  Bimanual  examination  may  assist  the 
diagnosis  when  part  of  the  head  can  be  felt  above  the  brim.  In 
general,  extraction  by  forceps  will  be  sufficient  to  meet  the  case. 
In  rare  cases  after  delivery  of  the  head,  detention  of  the  thorax 
takes  place  at  the  outlet  from  its  excessive  size,  and  may  even 
lead  to  the  sacrifice  of  the  child's  life.  If  moderate  and  cautious 
traction  on  the  neck,  in  conjunction  with  a  pain,  does  not  effect 
delivery,  the  finger  should  be  passed  into  the  vagina,  and  hooked 
into  the  posterior  axilla.  Traction  is  then  made  upon  the  axilla 
in  conjunction  with  that  upon  the  neck.  If  necessary  the  rotation 
of  the  shoulders  into  the  antero-posterior  diameter  of  the  pelvis 
should  be  aided.  If  the  finger  does  not  suffice,  the  small  blunt 
hook  used  in  version  (see  Cliapter  XXXIV.)  may  be  passed  round 
the  axilla,  and  traction  made  with  that.  Care  must  be  taken  that 
its  point  is  clear  of  the  axilla  on  the  other  side.     In  an  extreme 


688  The  Practice  of   Midwifery. 

case,  the  posterior  arm,  and  then,  if  necessary,  the  anterior  arm, 
may  be  drawn  down  over  the  chest,  so  as  practically  to  reduce  the 
dimensions  of  the  thorax. 

The  shoulders  may  also  be  arrested  higher  in  the  pelvis,  but  this 
very  rarely  happens  except  in  cases  where  there  is  pelvic  contraction, 
and  the  head  has  been  brought  through  the  brim  after  craniotomy. 
In  such  a  case,  space  having  been  gained  by  the  lessening  of  the 
head,  the  small  blunt  hook  may  be  fixed  in  the  posterior  axilla.  If 
this  does  not  succeed  the  arms  may  be  brought  down  by  the  aid  of 
the  same  instrument.  Afterwards  extraction  may  be  aided  by 
seizing  the  body,  either  the  thorax  or  the  abdomen,  with  the 
cephalotribe.  If,  with  an  after-coming  head,  extraction  of  the 
body  gives  great  trouble,  the  small  blunt  hook  may  be  used  to 
bring  down  the  arms.  The  child  being  dead,  space  may  be  gained, 
if  necessary,  by  cleidotomy  or  by  evisceration. 

General  Dropsy  of  the  F(etus. — General  dropsy  may  result 
from  a  variety  of  different  causes.  No  doubt  in  the  later  months 
it  may  arise  from  certain  maternal  diseases  which  increase  the 
blood  pressure  in  the  placenta  by  causing  structural  changes  in  the 
maternal  and  secondarily  in  the  fcetal  parts.  It  may  also  arise 
from  structural  anomalies  in  the  organs  of  the  foetus  (liver,  kidneys, 
heart,  blood)  which  directly  produce  the  dropsy.^  In  a  few  cases 
there  is  not  merely  infiltration  with  serum,  but  a  hyperplastic 
condition  of  the  subcutaneous  cellular  tissue  and  skin  (congenital 
cystic  elephantiasis).  Otherwise  the  skin  and  subcutaneous  tissues 
as  well  as  the  muscular  and  osseous  are  more  friable  than  usual. 
The  condition  is  frequently  associated  with  a  large  and  dropsical 
placenta. 

Treatment. — The  child  is  generally  incapable  of  surviving  long. 
In  case  of  difficulty,  therefore,  there  need  be  little  hesitation 
about  performing  craniotomy  ;  delivery  may  then  be  assisted  by 
fixing  the  small  blunt  hook  into  any  convenient  parts  of  the  body. 
The  swelling  may  also  be  diminished  by  making  incisions  or 
punctures  through  the  skin,  or  perforating  the  abdomen. 

Emphysema  of  the  Fcetus. — Emphysema  is  the  result  of 
decomposition  of  the  foetus  following  its  death  either  before  or 
during  labour,  and  the  access  of  air  to  it.  The  effusion  of  gas 
may  take  place  both  into  the  serous. cavities  and  into  the  cellular 
tissue.  In  the  latter  case  there  is  crackling  under  pressure  by 
the  finger.      At  the  same  time  the  tissues  become  friable.     The 

1  Ballantyne,  Antenatal  Pathology  :  The  Foetus,  1902,  p.  288. 


Labour  Obstructed  by  Anomalies  of  Ovum.     689 

abdomen  is  the  part  most  likely  to  cause  difficulty  in  delivery  by 
its  distension,  but  even  the  breech  and  limbs  may  become  con- 
siderably swollen. 

Treatment. — If  labour  is  obstructed,  the  accumulated  gas 
should  be  let  out,  especially  from  the  abdomen,  by  puncture  with 
the  perforator  or  any  other  convenient  instrument.  If  necessary, 
the  skin  of  the  breech  or  other  parts  may  be  incised  with  scissors. 
In  extraction,  it  is  to  be  remembered  that  the  limbs  are  liable  to 
tear  away. 

Congenital  Hydkocephalus. — In  congenital  hydrocephalus  there 
is    a   fluid   accumulation   within   the   ventricles  of   the   brain,  or 
(Fig.  344)  rarely  between  the  membranes.     The  dimensions  of  the 
child's  head  are  often  enormously  increased,  the  brain  being  spread 
out  as  a  thin  layer  over  the  serous  fluid.     The  average  diameter  of 
the  head  is  thus  not  very  rarely  increased  to  as  much  as  7  or  8 
inches  (17'5  to  20  cm.),  with  a  diameter  of  upwards  of  30  inches 
(75  cm.).     In  general  the  cranial  bones  are  thin,  soft,  and  spread 
out,  but  not  so  much  so  as  completely  to  cover  the  whole  surface. 
Thus  not  only  the  fontanelles,  but  the  sutures,  are  very  wide,  and 
the  bones  easily  movable  upon  each  other.     In  rare  cases,  esjDeeially 
when  the  effusion  is  moderate,  the  bones  are  more  firmly  ossified 
and  more  completely  cover  the  enlarged  head.     The  face  is  small 
relatively  to  the  head,  the  forehead  projecting  over  it  at  an  angle, 
the  frontal  suture  gaping.      The  body  may  be  of  normal  develop- 
ment, or  wasted.      Hydrocephalus  is  sometimes  associated   with 
spina   bifida,    club   feet,    encej)halocele,    or   hydrops   amnii.     The 
frequency  of  hydrocephalus  is  estimated  by  Lachapelle  as    1  in 
about  2,900  deliveries.     In  the  Guy's  Hospital  Charity,  however, 
perforation  or  puncture  on  account  of  hydrocephalus  was  called  for 
only  once  in  23,591  deliveries.     In  general,  interference  is  called 
for  in  about  three-fourths  of  the  cases.     Pelvic  presentations  are 
about  ten  times  commoner  than  in   normal  cases  (29  per  cent.), 
especially  when  the  distension  of  the  head  is  very  great,  for  then 
the  adaptation  of  the  child  to  the  uterus  takes  place  best  when  the 
head  is  uppermost  (see  Fig.  100,  p.  142). 

Course  and  Terminations. — When  the  amount  of  fluid  is 
moderate,  the  head  not  tense,  and  the  bones  soft,  the  head  may  be 
compressed  and  squeezed  through  the  pelvis  by  the  natural  powers. 
More  frequently  labour  becomes  arrested,  the  head  not  entering  the 
brim,  and  symptoms  of  protracted  labour  arise.  The  difficulty  in 
delivery  depends  not  only  upon  the  size  of  the  head,  but  upon  the 

M.  '  44 


690 


The  Practice  of   Midwifery. 


tension  of  the  fluid  in  it,  and  the  degree  of  ossification  of  the  bones. 
Sometimes  it  is  overcome  by  spontaneous  rupture  and  escape  of  the 
fluid,  especially  when  the  child  is  dead  and  decomposition  com- 
mencing. Spontaneous  delivery  occurs  more  easily  with  an  after- 
coming  head,  because  the  head  then  enters  the  pelvis  with  the 
narrower  end  of  the  wedge  foremost.  Compression  of  the  bones 
may  then  also  be  assisted  by  traction.     Kupture  of  the  uterus  is 


Fig.  344. — Labour  impeded  by  hydrocephalus. 


relatively  frequent.  It  occurred  in  30  cases  out  of  143  collected 
by  Keith  and  Schuchard.^  This  is  probably  to  be  explained  not 
only  by  the  obstruction  to  labour  and  a  failure  to  recognise  the 
condition,  but  by  the  large  size  of  the  head,  which  in  head  presenta- 
tions is  forced  down  into  the  lower  distensible  segment  of  the 
uterus,  as  the  upjDer  contractile  portion  retracts.  This  produces 
great  transverse  stretching,  and  thereby  a  tendency  to  longitudinal 
rupture. 

1  Schuchard,  Inaug.  Diss.,  Berlin,  1884. 


Labour  Obstructed  by  Anomalies  of  Ovum.     691 

Prognosis. — The  mortality  to  the  mothers  is  high,  46  deaths 
occurring  in  246  cases,  or  18  per  cent.  There  is,  however,  Kttle 
danger  if  the  case  is  early  recognised  and  treated.  The  risk  lies  in 
its  nature  being  overlooked.  The  child  generally  perishes,  and,  in 
any  case,  it  is  not  capable  of  prolonged  life ;  of  70  cases  recorded 
by  V.  Winckel,^  with  17  living  children,  7  died  within  a  few  days, 
and  the  remainder  lived  for  a  varying  time. 

Diagnosis. — In  head  presentations,  the  head  will  be  high  up, 
not  entering  the  brim,  and  the  presenting  j)art  may  be  made  out 
as  less  convex  than  usual,  forming  part  of  a  larger  spheroid.  The 
wide  fontanelles  and  sutures,  soft  bones,  and  comj)ressible  character 
of  the  head  generally  render  the  diagnosis  easy.  The  head  is 
distinguished  from  the  bag  of  membranes  or  cystic  tumours  of  the 
foetus  by  the  presence  of  hair,  and  of  the  cranial  bones.  If  the 
bones  are  much  ossified,  diagnosis  is  more  difficult,  and  the  whole 
hand  should  be  introduced  into  the  vagina  for  exploration  if  neces- 
sary. The  brow  may  then  perhaps  be  reached,  and  the  overhang- 
ing forehead  and  open  frontal  suture  made  out.  Another  most 
valuable  means  of  diagnosis  is  the  estimation  of  the  size  of  the 
head  bimanually,  since  from  its  magnitude  and  high  position  it  can 
usually  be  defined  quite  easily  from  the  abdomen.  In  general  there 
will  be  urgent  pains,  combined  with  failure  of  the  head  to  descend, 
and  the  absence  of  any  pelvic  contraction  to  account  for  this.  The 
urgency  of  pains  is  not,  however,  always  noted,  if  the  head  fails  to 
enter  the  brim  at  all.  If  forceps  are  applied,  they  often  slip  off,  in 
consequence  of  the  collapsible  character  of  the  head.  If  the  bones 
are  firmly  ossified,  the  handles  may  remain  widely  separated  when 
the  forceps  are  locked.  When  the  pelvis  presents,  the  presence  of 
hydrocephalus  is  generally  only  discovered  when  the  head  cannot 
be  brought  into  the  brim.  The  unusual  size  of  the  uterine  tumour 
and  bimanual  estimation  of  the  size  of  head  will  then  generally 
reveal  the  true  state  of  the  case. 

Treatment. — Forceps  will  generally  slip  off  the  head,  and  it  is 
not  usually  worth  while  to  attempt  delivery  by  version,  since  the 
child  is  seldom  capable  of  prolonged  life.  For  the  same  reason 
there  is  little  object  in  puncturing  with  a  small  trocar,  in  order  to 
secure  a  living  child,  unless  it  should  be  of  legal  importance  to 
secure  the  birth  of  a  child,  even  though  it  lives  for  only  a  short 
time.  The  distended  head  may  be  punctured  with  the  perforator, 
by  preference  in  an  interval  between  bones,  near  the  most  prominent 

1  v.  Winckel,  Lehrbuch  der  Geburtshiilfe,  1893,  p.  394. 

44—2 


692  The  Practice  of   Midwifery. 

part.  If  it  does  not  quickly  descend,  it  is  then  extracted  by 
craniotomy  forceps  or  cephalotribe.  If  an  after-coming  head 
cannot  be  drawn  through  the  brim,  it  should  be  perforated  in  the 
manner  described  in  the  chapter  on  craniotomy.  A  possible  alter- 
native is  to  let  off  the  fluid  by  a  catheter  passed  through  the  spinal 
canal  into  the  cranial  cavity. 

Ascites,  Hydrothoeax,  Distension  of  Abdomen. — Ascites  and 
hydrothorax  may  arise  from  chronic  intra-uterine  inflammation  of 
the  fcetus,  due  to  syphilis  or  other  causes,  or  to  malformation  or 
obstruction  of  veins.  Hydrothorax  is  very  rare,  except  in  associa- 
tion with  ascites.  The  abdominal  distension  is  most  likely  to  be 
the  cause  of  difficulty  in  labour,  but,  on  account  of  the  yielding 
nature  of  the  abdominal  walls,  this  is  only  the  case  when  distension 
is  considerable.  Another  cause  of  abdominal  distension  is  occlusion 
of  the  urethra  or  ureters  from  malformation  or  inflammation.  The 
foetal  urine  secreted  then  accumulates,  and  produces  distension  of 
the  bladder,  ureters,  or  kidneys,  according  to  circumstances.  I  have 
found  it  necessary,  in  order  to  effect  delivery,  in  a  case  of  jDelvic 
presentation,  to  perforate  first  the  bladder,  and  then  two  cystic 
tumours  formed  by  the  ureters.  Here  there  was  occlusion  both  of 
the  urethra  and  of  the  lower  part  of  the  ureters,  the  latter  probably 
being  of  later  date.  The  abdomen  may  also  be  distended  by  other 
causes,  which  less  frequently  lead  to  enlargement  great  enough  to 
call  for  interference.  Among  such  cases  recorded  are  enlargements 
or  tumours  of  the  liver,  kidneys,  spleen,  or  pancreas,  and  an 
included  foetus  situated  in  the  abdomen.  In  the  latter  case  one 
ovum  appears  to  be  included  within  another,  and  to  undergo  partial 
development,  deriving  its  nourishment  by  its  attachment  to  the  other. 

Diagnosis. — The  morbid  condition  is  generally  first  discovered 
when  the  foetus  will  not  advance  after  the  head  has  passed  through 
the  pelvis.  The  hand  being  then  passed  up  to  ascertain  the  cause, 
enlargement  of  the  abdomen  or  thorax  is  detected.  A  complete 
diagnosis  is  generally  impossible  till  after  delivery. 

Treatment. — In  minor  degrees  of  enlargement,  delivery  may 
be  effected  by  traction  upon  the  head  with  forceps,  or  after  its 
delivery,  or  by  traction  on  the  legs  in  pelvic  presentations.  If  this 
does  not  succeed,  the  abdomen,  or  if  necessary  the  thorax,  should 
be  pierced  with  a  trocar  and  cannula.  In  the  absence  of  a  trocar, 
the  perforator  may  be  used  to  pierce  the  abdomen,  unless  there  is 
legal  importance  in  securing  a  child  to  live,  if  only  for  a  short 
time.      If  the  perforator  is  used  in  a  cranial  presentation   it  is 


Labour  Obstructed  by  Anomalies  of  Ovum.     693 

better  to  perforate  also  the  head,  and  destroy  the  medulla  (see 
Chapter  XXXV.)?  lest  a  living  child  be  born  with  a  lacerated 
abdomen.  If  the  cause  of  obstruction  proves  to  be  solid,  it  may 
be  necessary  to  perform  complete  evisceration,  and  perhaps  to 
apply  the  cephalotribe  over  the  abdomen  for  extraction. 

Congenital  Encephalocele.  —  In  congenital  encephalocele  a 
serous  sac  is  applied  to  the  head  by  a  base  or  pedicle  of  varying 
breadth.  It  is  filled  with  cerebro-spinal  fluid,  originally  continuous 
with  that  in  the  head.  Generally  the  communication  still  exists  at 
birth,  but  the  pedicle  may  be  found  impervious  when  of  small  size. 
Cerebral  substance  may  or  may  not  be  spread  out  more  or  less  over 
the  surface  of  the  sac.     Encephaloceles  are  most  frequently  situated 


Fig.  345.— Encephalocele.     (Meigs.i) 

in  the  middle  line.  The  commonest  seat  is  the  occiput  (Fig.  345), 
next  to  that  the  frontal  region.  They  may  be  of  any  size 
up  to  one  considerably  larger  than  the  head  itself.  Difficulty  in 
parturition  is  generally  produced  only  when  the  sac  is  of  large  size, 
since  from  its  position  it  generally  passes  through  the  pelvis  in 
front  of  or  behind  the  head,  and  is  compressible.  In  the  case 
figured,  one  recorded  by  Dr.  Meigs,  the  head  was  born  first,  and 
then,  the  sac  remaining  above  the  pubes,  the  rest  of  the  body  was 
born  by  spontaneous  evolution.  The  sac  was  then  delivered  intact 
by  powerful  traction.  The  sac  may  be  mistaken  for  a  second  bag 
of  membranes.  In  case  of  delay  the  diagnosis  must  be  made  by 
passing  the  hand  high  up  into  the  pelvis. 

Treatment. — If  traction  is  not  sufficient  to  effect  delivery,  the 
sac  should  be  punctured  by  trocar. 

1  The  Science  and  Art  of  Obstetrics,  1863,  p.  409. 


694  The  Practice  of   Midwifery. 

Spina  Bifida.^ — In  spina  bifida  a  similar  serous  sac,  its  contents 
generally  continuous  with  the  cerebro-spinal  fluid,  is  situated  over 
the  lumbo-sacral  region.  Its  size  may  be  as  large  as  that  of  a  foetal 
head.  In  this  case  also  the  sac  has  to  be  distinguished  from  a  bag 
of  membranes,  especially  if  it  presents  alone  at  the  os. 

Treatment. — If  delivery  cannot  be  effected  by  traction,  the  sac 
must  be  j)unctured. 

Othek  External  Tumours. — Tumours  growing  externally,  of 
cystic,  fatty,  cancerous,  or  other  structure,  are  a  rare  cause  of 
difficulty  in  parturition.  They  may  be  situated  on  the  neck,  chest, 
axillae,  and  other  parts,  but  especially  about  the  sacral  region.  The 
most  common  tumour  in  this  situation  is  a  cysto-hygroma,  which 
may  attain  considerable  size. 

Treatment. — Puncture  should  first  be  tried,  if  delivery  cannot 
be  effected  with  the  tumour  intact.  If  this  does  not  succeed,  it 
may  be  necessary  to  incise  or  crush  it. 

Anomalies  of  the  Membranes. — Undue  friability  of  the  mem- 
branes leads  to  their  premature  rupture,  and  consequent  prolonga- 
tion of  the  first  stage  of  labour.  The  effects  of  undue  toughness 
are  generally  obviated  by  artificial  rupture.  If  not,  the  membranes 
may  remain  intact  in  the  second  stage,  as  they  have  done  in  the 
case  shown  in  the  frozen  section  (Fig.  131,  p.  220).  The  second 
stage  is  then  prolonged,  both  from  the  less  vigorous  action  of  the 
uterus,  and  from  the  larger  size  of  the  body  to  be  expelled.  Some- 
times the  child,  when  small,  is  even  expelled  with  the  membranes 
intact.  It  then  quickly  perishes  from  asphyxia,  unless  the  sac  is 
artificially  ruptured.  A  child  born  with  the  membranes  over  its 
head  is  j)opularly  said  to  be  born  with  a  "  caul."  ^ 

When  the  child  is  born  with  a  caul,  or  even  when  the  bag  of 
membranes  descends  far  in  advance  of  the  presenting  part,  special 
care  should  be  taken  to  see  that  none  of  the  chorion  is  left  behind 
in  the  uterus.  For  the  amnion  usually  presents  alone  in  such 
cases,  separated  from  the  chorion  (see  p.  223) ;  and  the  aid  to  the 
separation  of  the  chorion,  afforded  by  its  attachment  to  the  amnion, 
thereby  fails. 

Undue  Shortness  of  the  Funis. — Obstruction  to  labour  may 
arise  from  either  actual  or  relative  shortness  of  the  funis,  but  much 
more  commonly  from  the  latter.     Eelative  shortness  arises  from 

1  From  calea,  a  helmet. 


Labour  Obstructed  by  Anomalies  of  Ovum.     695 

the  funis  being  wound  round  some  part  of  the  foetus,  generally- 
round  the  neck.  Thus  an  actually  long  funis,  when  wound  two  or 
three  times  round  the  neck,  may  become  a  relatively  short  one. 
Moreover,  since  the  neck  is  as  much  as  three  inches  further  from 
the  placental  insertion  than  the  umbilicus,  the  available  length  has 
to  be  so  much  the  greater  when  the  funis  is  round  the  neck,  if  no 
obstruction  is  to  arise.  According  to  Matthews  Duncan's  experi- 
ments,^ the  average  length  of  a  normal  funis  was  found  to  be 
17|  inches,  and  the  average  stretching  under  tension  before 
breakage  amounted  to  one-sixth  of  the  original  length.  The 
average  breaking  strain  was  8 J  lb.,  the  weakest  funis  requiring 
51  lb.,  the  strongest  15  lb.,  to  break  it.  The  breaking  strain 
gives  the  limit  to  the  force  obstructing  labour  which  a  funis 
can  exert. 

Extreme  actual  shortness,  such  as  a  length  of  four  inches  or  less, 
is  excessively  rare.  Monsters  occur,  however,  in  which  there  is  no 
funis,  the  extroverted  viscera  being  in  direct  contact  with  the 
placenta.  In  such  cases  even  the  earlier  part  of  the  expulsive 
stage  of  labour  might  be  affected.  In  general  the  placental  as  well 
as  the  foetal  attachment  descends  to  some  extent  in  the  earlier  part 
of  labour,  and  the  funis  is  therefore  less  likely  to  be  put  early  upon 
the  stretch.  It  is  very  rare  for  the  funis  to  cause  obstruction  before 
the  birth  of  the  head,  or  that  of  the  breech  in  pelvic  presentations. 
More  commonly  obstruction  arises  after  birth  of  the  head,  and  still 
more  commonly  after  that  of  the  shoulders,  the  cause  being  generally 
the  winding  of  the  funis  round  the  neck. 

Results  and  Terminations. — The  result  may  be  rupture  of  the 
funis,  separation  of  the  placenta  before  delivery,  or  inversion  or 
partial  inversion  of  the  uterus.  Inversion  has  been  recorded  as 
due  to  this  cause,  but  is  very  rare,  since  the  funis  is  only  put  on 
the  stretch  when  the  uterus  is  acting,  and  therefore  not  prone  to 
become  inverted.  Probably  it  could  only  occur  through  artificial 
traction.  The  most  common  result,  if  the  funis  is  wound  round  the 
neck,  and  no  artificial  relief  is  given,  is  that  birth  takes  place  by  a 
kind  of  spontaneous  evolution.  The  neck  is  fixed  under  the  pubic 
arch  by  the  tight  funis.  The  tension  causes  a  partial  undoing  of 
the  twist  round  the  neck,  and  so  rotates  the  foetus  with  its  abdomen 
forward.  Then  evolution  takes  place  by  a  rotation  of  the  body 
round  the  point  where  the  neck  is  fixed  by  the  funis  as  a  centre, 
accompanied  by  a  doubling  up,  the  body  coming  down  posteriorly. 

1  "  On  S?iortncsH  of  tfie  Cord  as  a  CauHC  of  Obstruction  to  the  Natural  I'rogress  of 
Labour,"  Trans.  Obst.  Soc.  London,  1881,  Vol.  XXIIL,  p.  248. 


696  The  Practice  of   Midwifery. 

It  is  somewhat  analogous  to  spontaneous  evolution  in  shoulder  pre- 
sentation, where  the  rotation  is  round  the  point  where  the  neck  is 
fixed  against  the  pelvic  brim.  The  fcetus  may  be  asphyxiated 
meantime  by  the  pressure  of  the  funis  round  its  neck,  together  with 
the  retention  of  the  chest  within  the  vagina. 

Diagnosis. — In  the  rare  case  of  obstruction  caused  by  the  funis 
before  delivery  of  the  head,  diagnosis  is  difficult.  Shortness  of  the 
funis  may  be  suspected  if  the  head  is  arrested,  though  not  tightly 
grasped  in  the  genital  passages,  and  recedes  in  a  marked  way  in 
the  interval  of  pains,  still  more  if,  in  addition,  ante-par  turn 
haemorrhage  occurs  when  the  head  is  in  the  vagina,  not  accounted 
for  by  vaginal  or  cervical  laceration.  A  coil  of  the  funis  round  the 
neck  may  possibly  be  detected  on  rectal  examination.  In  general, 
the  head  would  have  to  be  delivered  by  forceps  without  exact 
diagnosis  of  the  cause  of  delay.  In  pelvic  presentation,  tension  of 
the  funis  would  be  more  easily  detected,  the  hand  being  passed  up 
to  ascertain  the  cause  of  difficulty.  One  of  the  symptoms  given 
is  special  pain  at  the  placental  site  during  a  uterine  contraction, 
or  when  traction  is  made  on  the  foetus.  There  may  possibly  be  a 
recognisable  depression  at  the  placental  site,  if  traction  is  made  on 
the  fcetus  when  the  uterus  is  lax.  Dr.  Braxton  Hicks  ^  has  recorded 
a  case  in  which  a  funis  only  four  inches  long  had  to  be  divided 
within  the  uterus. 

Treatment. — As  soon  as  the  head  appears,  if  a  coil  of  the  funis 
round  the  neck  is  discovered,  the  funis  should  be  drawn  down  as 
much  as  possible  so  as  to  slacken  the  looj),  and  the  loop  or  loops 
passed  over  the  head,  or,  if  this  is  impossible,  over  the  shoulders. 
If  it  is  too  late  thus  to  release  the  coil,  or  if  the  pains  are  too  rapid 
and  violent  to  allow  it,  and  the  funis  is  drawn  tight,  or  impedes  the 
advance  of  the  child,  the  funis  should  be  divided  with  scissors. 
The  fcetal  end  may  be  compressed  between  the  finger  and  thumb 
until  after  the  delivery  of  the  child,  accelerated,  if  necessary,  by 
traction,  and  then  it  should  be  tied  in  the  usual  way.  Impediment 
due  to  absolute  shortness  of  the  funis  should  be  treated  in  the 
same  way  by  division. 

1  Trans.  Obst.  Soc.  London,  1881,  Vol.  XXIII.,  p.  253, 


Chapter   XXIX- 
ANOMALIES  OF  THE  PELVIS. 

Enla7'ged  Pelves. 

A  PELVIS  larger  than  the  normal  may  occur  simply  as  a  part  of 
the  general  large  size  of  the  body.  In  general,  however,  it  is  not 
specially  tall  women  who  have  large  pelves,  but  rather  those  who 
are  broad,  and  have  the  feminine  characteristics  well  marked, 
sometimes  even  though  they  may  be  below  the  average  height. 
Tall  muscular  women  often  have  a  pelvis  rather  small  in  propor- 
tion to  their  size.  A  large  pelvis  is  generally  normal  in  its 
proportions,  and  is  then  called  the  Pelvis  ALquabiliter  Justo  Major. 
In  some  cases  there  may  be  an  exaggerated  development  of  the 
special  characteristics  of  the  female  pelvis,  particularly  of  the 
relatively  wide  transverse  diameter.  In  cases  of  double  uterus,  a 
marked  increase  in  the  transverse  diameter  has  been  noted. 

An  enlarged  pelvis  cannot  be  regarded  as  a  pathological  con- 
dition. The  only  disadvantages  likely  to  arise  from  it  are  the 
inconveniences  which  may  result  from  precipitate  labour.  On  the 
whole  it  may  be  considered  an  advantage  to  have  a  pelvis  above 
the  average  size.  It  has  been  stated  that  labour  is  not  necessarily 
easy  in  large  pelves,  because  from  want  of  close  adaptation  the 
head  may  fail  to  undergo  the  usual  rotations.  These  rotations, 
however,  depend  to  a  considerable  extent  on  the  soft  parts,  and  it 
appears  that  the  head  does  undergo  them,  so  far  as  is  necessary  for 
its  easy  delivery. 

Contracted  Pelves. 
General  Forces  concerned  in  the  Production  of  Pelvic 
Deformities. — The  forces  upon  which  the  shape  of  the  pelvis 
chiefly  depends  are  the  vital  forces  of  growth  and  development, 
the  effect  of  the  body-weight  and  the  resistances  which  it  calls  out, 
and  the  pressure  and  traction  of  muscles  and  ligaments.  The 
results  of  these  may  be  seen  in  all  forms  of  deformed  pelves  as 
well  as  in  the  development  of  the  normal  pelvis.  When  the  bones 
are  softened,  the  effects  of  the  mechanical  forces  are  exaggerated. 
In  many  forms  of  distortion  the  shape  of  the  pelvis  depends 
upon  the  alteration  of  the  points  of  application  of  the  mechanical 


698  The   Practice  of   Midwifery. 

forces  owing  to  some  local  want  of  development  or  disease,  or  to 
deformities  or  injuries  of  the  spine  or  limbs. 

In  relation  to  the  views,  already  mentioned,  of  Breus  and  Kolisko,^ 
in  regard  to  the  development  of  the  pelvis  and  the  large  part 
played  by  the  normal  forces  of  the  growth  of  the  bones,  it  is 
necessary  to  see  what  effect  their  views  will  have  in  elucidating 
the  etiology  of  contracted  pelves.  They  maintain  that  a  very 
important  factor  is  the  maldevelopment  of  certain  portions  of  the 
bones  composing  the  pelvis,  especially  the  ilium  and  the  sacrum. 
They  consider  that  the  shortening  of  the  conjugate  diameter  of  the 
brim  is  rather  to  be  explained  by  an  imperfect  development  of  the 
iliac  portion  of  the  innominate  bone  than  by  any  displacement  or 
rotation,  the  result  of  mechanical  causes,  of  the  sacrum.  At  the 
same  time  they  hold  that  there  is  not  that  marked  rotation  of 
the  sacrum  which  has  been  described,  but  that  the  alteration  in 
the  position  of  this  bone  is  due  rather  to  a  want  of  the  displace- 
ment backwards  of  the  sacro-iliac  joint  which  should  occur  in  the 
normal  development  of  the  pelvis. 

No  doubt  the  imperfect  development  of  different  portions  of  the 
component  bones  of  the  pelvis  plays  an  important  part  in  the  pro- 
duction of  various  kinds  of  deformed  pelves,  but  at  the  same  time 
it  is  impossible  to  ignore  the  effect  of  various  mechanical  causes 
acting  on  the  bones. 

The  mechanical  forces  which  influence  the  shape  of  the  normal 
pelvis  in  growth  from  infancy  to  adult  life,  and  the  exaggerated  or 
uncounteracted  or  one-sided  influence  of  which  is  concerned  in  the 
production  of  many  pelvic  deformities,  have  already  been  described 
(see  pp.  25 — 33).  The  reader  is  recommended  to  refer  back  to 
that  description  before  reading  the  account  of  the  mode  of  pro- 
duction of  the  varieties  of  deformed  pelvis.  Certain  influences 
which  are  in  action  in  the  formation  of  all  varieties  of  pelvis  will 
here  be  briefly  recapitulated. 

(1.)  Effect  of  the  Pelvic  Inclination. — If  pelvic  inclination 
is  increased  beyond  the  normal  angle,  the  sacrum  tends  to  sink 
more  towards  the  centre  of  the  pelvic  brim,  and  the  effect,  both  of 
the  body- weight  and  of  the  traction  of  the  abdominal  muscles,  in 
widening  the  pelvis  transversely  and  flattening  it  antero-posteriorly, 
is  increased.  If  pelvic  inclination  is  diminished,  the  contrary  effects 
are  produced,  and  the  tendency  is  to  increase  the  antero-posterior 
and  diminish  the  transverse  diameter  of  the  pelvis.      At  the  same 

^  Breus  and  Kolisko,  Pathologischen  Beckenformen,  1900. 


Anomalies   of  the    Pelvis.  699 

time  the  sacrum  tends  to  sink  down  more  deeply  between  the  ilia 
in  the  direction  of  the  coccyx. 

(2.)  Effect  of  Standing,  Walking,  etc. — The  effect  of  standing, 
walking,  or  running  is  to  call  into  play  the  inward  pressure  of  the 
heads  of  the  femora  upon  the  acetabula  due  to  muscular  action 
(see  p.  28),  as  well  as  the  reaction  to  the  body- weight.  Hence  the 
tendency  of  the  body-weight  to  widen  the  pelvis  through  the 
leverage  exerted  upon  the  innominate  bones  (see  p.  27)  is  resisted 
by  the  inward  pressure  at  the  acetabula  more  in  children  who 
stand,  walk,  and  run  much  than  in  those  who  are  constantly  sitting. 
This  principle  is  especially  illustrated  by  the  form  of  almost 
uniformly  contracted,  not  flattened,  pelvis,  occasionally  met  with 
as  the  result  of  rachitis,  as  contrasted  with  the  usual  flattened 
rachitic  pelvis.  Such  a  form  of  pelvis  is  attributed  to  the  occur- 
rence of  rachitis  at  rather  a  later  age  than  usual,  so  that  the 
child  is  not  constantly  sitting,  but  standing  and  moving  about. 

If  one  or  both  acetabula  are  for  any  cause  displaced  inwards 
towards  the  middle  line,  the  effect  of  the  reaction  to  the  body- 
weight  is  altered.  It  has  been  already  explained  that  this  reaction 
is  directed  vertically  upwards  (see  p.  28).  Its  effect  upon  the  shape 
of  the  pelvic  brim  depends  upon  that  of  its  component  resolved  in 
a  plane  parallel  to  the  brim  (see  Fig.  25,  p.  27).  If  the  acetabulum 
is  nearer  the  middle  line  than  the  sacro-iliac  joint  the  line  of  this 
force  will  fall  inside  the  fulcrum  of  the  lever  instead  of  outside, 
and  the  force  will  therefore  tend  to  thrust  the  lower  end  of  the 
lever  inwards  instead  of  outwards.  Hence,  if  an  acetabulum  is 
displaced  inwards  nearer  to  the  middle  line  than  the  sacro-iliac 
joint,  the  reaction  to  the  body- weight  assists  the  inward  thrust  of 
the  muscular  force  acting  on  the  femur  instead  of  tending  to 
counteract  it.  If  the  acetabulum  is  displaced  inwards  in  any  degree 
at  all,  the  counteracting  force  to  the  inward  thrust  is  diminished.  An 
instance  of  this  effect  occurs,  as  will  shortly  be  described,  on  both 
sides  in  the  triradiate  pelvis,  whether  of  the  malacosteon  or 
pseudo-malacosteon  form,  on  one  side  in  the  various  forms  of 
oblique  pelvis. 

Effect  of  Sitting. — It  has  already  been  explained  (see  p.  30) 
that,  in  sitting,  the  body-weight  tends  to  widen  the  whole  pelvis 
by  the  leverage  it  exerts  on  the  innominate  bones,  and  also  that 
the  reactions  to  the  body-weight  through  the  tubera  ischii  tend  to 
rotate  the  lower  part  of  each  innominate  bone  outwards  on  an  axis 


700  The  Practice  of   Midwifery. 

joining  the  centres  of  the  symphysis  pubis  and  sacro-iliac  synchon- 
drosis, and  so  specially  to  widen  the  pelvic  outlet,  increasing  the 
distance  between  the  tubera  ischii,  and  widening  the  pubic  arch. 
In  the  case  of  congenital  absence  of  the  legs,  where  the  woman 
can  sit,  but  not  stand,  the  pelvis,  both  at  brim  and  outlet,  has 
been  found  wider  than  normal,  the  inward  thrust  at  the  acetabula 
being  wanting. 

As  in  the  case  of  the  acetabula,  the  action  of  the  force  is 
diminished,  and  eventually  reversed,  if  the  tuber  ischii  is  displaced 
inwards.  If  the  tuber  ischii  lies  nearer  the  middle  line  than  the 
sacro-iliac  joint,  the  tendency  will  be  to  thrust  the  anterior  end  of 
the  innominate  bone  inwards  instead  of  outwards  ;  if  it  lies  inside 
the  line  joining  the  centres  of  the  symphysis  pubis  and  sacro-iliac 
synchondrosis,  the  tendency  will  be  to  rotate  the  lower  part  of 
the  innominate  bone  inwards  instead  of  outwards.  If  the  usual 
widening  effect  is  merely  diminished  owing  to  partial  displacement 
inward  of  the  tuber  ischii,  the  inward  tension  of  the  sacro-sciatic 
ligaments  may  be  sufficient  to  overcome  it.  On  the  contrary,  if 
the  pelvis  is  wider  than  normal,  the  tendency  of  sitting  to  widen 
the  outlet  is  yet  further  increased.  Hence  the  general  rule  is  that 
a  pelvis  relatively  wide  at  the  brim  is  still  wider  at  the  outlet,  and 
a  pelvis  transversely  contracted  at  the  brim  is  still  more  contracted 
at  the  outlet.  The  principle  is  also  illustrated  both  in  the  triradiate 
pelvis,  and  in  oblique  pelves. 

Diagnosis  of  Pelvic  Contraction. — The  general  diagnosis  of 
pelvic  contraction  will  be  considered  before  the  special  varieties  of 
pelvis  are  described.  General  indications,  such  as  may  be  obtained 
from  a  person's  aj)pearance,  denote  usually  simply  the  probability 
that  some  pelvic  deformity  may  exist  rather  than  its  nature  or 
degree.  They  are  chiefly  of  use  in  showing,  in  the  case  of  a 
woman  pregnant  for  the  first  time,  when  it  is  desirable  to  make  a 
local  examination  as  to  the  capacity  of  the  pelvis  before  the  full 
term  arrives,  and  so  possibly  avoid  a  very  difficult  and  dangerous 
delivery  by  the  induction  of  premature  labour  or  other  means. 
Such  indications  consist  in  smallness  of  the  whole  figure,  especially 
if  accompanied  by  slenderness,  relative  shortness  of  limbs,  pointing 
to  the  probability  of  rachitis,  spinal  curvatures,  lameness,  especially 
if  due  to  shortness  of  one  leg,  undue  hollowness  of  the  back, 
pointing  to  the  probability  of  excessive  pelvic  inclination,  any 
other  deformity  affecting  the  back  or  legs,  and  in  a  primipara  a 
pendulous  abdomen  and  non-fixation  of  the  head  in  the  brim  in 
the  last  few  weeks  of  pregnancy.     Attention  should  be  paid  to  any 


Anomalies  of  the   Pelvis. 


701 


history  of  rickets,  or  other  disease  of  bones,  or  of  any  disease  or 
injury  affecting  the  back,  pelvis,  or  legs.  Rickets  may  also  be 
revealed  by  curvature  and  thickening  of  the  tibiae.  If  previous 
deliveries  have  occurred,  the  history  of  the  course  of  parturition 
is  the  most  important  guide  of  all. 

Pelvimetry. — For  the  exact  diagnosis  of  pelvic  deformity,  it  is 
necessary  to  take  certain  external  and  internal  measurements. 
The  external  measurements  are  obtained  with  ease,  but  do  not 
allow  any  exact  inferences  to  be  made  as  to  the  size  of  the  pelvic 
canal,  which  is  the  only  point  of  real  importance.  They  are  of 
value,  because  they  not  only  give  evidence,  in  many  cases,  of  the 
existence  of  deformity  in  the  canal,  although  not  of  its  precise 
degree,  but  often  indicate  the  general  character  of  the  pelvic 
distortion,  as,  for  instance,  that  it  is  due  to  rickets,  or  that  oblique 


Fig.  346. — Pelvimeter. 


distortion  exists.  The  form  of  pelvimeter  used  for  external 
measurements  is  shown  in  Fig.  346.  It  is  simply  a  modifica- 
tion of  the  ordinary  callipers  used  by  carpenters,  having  an 
index  near  the  hinge,  from  which  the  distance  separating  the 
points  can  be  read  off.  One  arm  may  be  made  straight,  if  it  is 
desired  to  have  an  instrument  which  may  be  used  for  measuring 
the  thickness  of  the  bones,  with  one  arm  in  the  vagina  and  one 
outside.  The  internal  measurements  are  of  most  direct  import- 
ance, but  are  more  difficult  to  obtain  with  exactness.  Various 
pelvimeters  have  been  invented  for  taking  them,  but  on  the  whole 
the  fingers  are  to  be  preferred  to  any,  and  therefore  no  description 
of  these  special  forms  will  be  given.  The  fingers  can  be  used  with 
less  pain  to  the  patient,  and  being  sentient,  are  less  likely  to  lead  to 
the  fallacy  which  may  arise,  if  the  points  of  the  pelvimeter  are 
not  in  reality  exactly  where  they  are  supposed  to  l)e. 

External  Measurements, — The  most   important   of  the   external 


702  The  Practice  of   Midwifery. 

measurements  are  two,  the  distance  between  the  anterior  superior 
spines  of  the  ihum  (Dist.  Sp.  II,),  and  the  maximum  distance 
between  the  outsides  of  the  iliac  crest  (Dist.  Cr.  II.) .  These  distances 
are  normally  about  10  inches  (25  cm.)  and  lOf  inches  (26*8  cm.) 
respectively.  For  the  measurement  the  patient  is  placed  on  her 
back,  and  may  be  covered  with  a  thin  garment.  For  the  first 
measurement  the  tips  of  the  callipers  are  placed  outside  the  spines. 
For  the  second  the  callipers  are  set  at  the  smallest  width  which 
will  allow  them  to  pass  over  the  widest  part  of  the  crests,  or  over 
their  centres  about  2^  inches  (6  cm.)  posterior  to  the  spines, 
if  the  spines  are  wider  apart  than  any  other  portion  of  the  crests. 

Contraction  of  the  pelvis  may  be  indicated  by  one  of  two 
things.  (1.)  The  distances  may  both  be  less  than  normal. 
(2.)  The  relation  between  them  may  be  altered  in  such  way 
that  either  the  distance  between  the  spines  is  greater  than  the 
distance  between  the  crests  at  any  other  point,  or  at  any  rate  is 
not  exceeded  in  the  usual  proportion  by  the  maximum  distance 
between  the  crests.  If  the  spines  are  wider  apart  than  any  other 
part  of  the  crests,  the  pelvis  is  flattened  and  rachitic,  with  a 
greatly  contracted  conjugate  diameter.  If  even  the  excess  of  the 
maximum  distance  over  that  between  the  spines  is  less  than  in 
due  proportion,  the  pelvis  is  probably  flattened  and  rachitic. 
One  exception  to  this  rule,  however,  occurs  in  some  cases  of  the 
rachitic  generally  contracted  pelvis,  in  which  the  relation  between 
the  two  distances  is  altered  in  this  way,  but  the  pelvis  is  not 
flattened.  If  not  only  the  relation  of  the  two  distances  is  altered, 
but  the  mean  of  the  two  is  too  small,  there  is  a  generally  con- 
tracted pelvis,  which  is  also  probably  flattened.  If,  on  the  other 
hand,  the  due  relation  between  the  two  distances  is  preserved, 
but  both  are  smaller  than  the  normal,  there  is  jDrobably  a  generally 
contracted  pelvis,  without  flattening.  There  may  also  be  one  of 
the  rarer  forms  of  pelvis,  contracted  in  the  transverse  diameter ; 
but  in  this  case  the  external  conjugate  diameter  will  be  above 
rather  than  below  the  average  ;  while,  in  the  generally  contracted 
pelvis,  it  is  below  the  average. 

The  transverse  diameter  of  the  brim  may  be  roughly  calculated 
from  the  transverse  diameter  of  the  false  pelvis.  If  the  measure- 
ment is  taken,  not  as  usual  from  the  outside,  but  from  the  summit 
of  the  iliac  crests,  half  its  magnitude  will  give  the  transverse 
diameter  of  the  pelvic  brim,  with  only  a  slight  margin  of  error. 

The  external  measurement  next  in  importance,  but  of  inferior 
value  to  these  transverse  diameters,  is  the  external  conjugate 
diameter  (C.   Ext.).      In    measuring    this,  the  patient   is   placed 


Anomalies  of  the  Pelvis.  703 

upon  her  side ;  one  point  of  the  callipers  is  placed  in  front  of  the 
top  of  the  symphysis  pubis,  the  other  just  below  the  spinous  process 
of  the  last  lumbar  vertebra.  The  external  conjugate  is  on  the  average 
about  7^  inches  (18'7  cm.).  The  object  of  measuring  this  distance 
is  to  calculate  from  it  the  probable  size  of  the  internal  true  conjugate 
diameter.  It  does  not,  however,  lie  exactly  in  the  pelvic  brim, 
for  the  plane  of  the  brim  passes  above  the  spinous  process  of  the 
last  lumbar  vertebra,  as  may  be  seen  from  the  frozen  section. 
Fig.  131,  p.  220.  Moreover,  the  amount  to  be  deducted  from  the 
thickness  of  the  bones  and  soft  parts  varies  very  widely  in  different 
cases,  the  difference  being  as  much  as  an  inch,  or  even  more. 
Especially  in  the  rachitic  pelvis,  the  thickness  of  the  sacrum,  where 
the  projecting  promontory  is  formed,  is  apt  to  be  greater  than 
usual.  The  thickness  of  the  external  soft  parts  is  also  variable. 
Hence  moderate  values  of  the  external  conjugate,  such  as  those 
between  7  (17-5  cm.)  and  7  J  inches  (18-7  cm.),  give  little  information 
about  the  state  of  the  pelvis.  It  is  only  from  more  extreme  values 
that  any  positive  conclusions  can  be  drawn,  and  even  then  only  as 
to  the  fact  of  contraction  or  its  absence,  and  not  as  to  the  degree. 
Thus  if  the  external  conjugate  measures  over  7^  inches  (18'7  cm.), 
it  is  pretty  certain  that  there  is  no  flattening ;  if  it  is  under  7  inches 
(17'5cm.),  a  contracted  conjugate  may  be  inferred. 

It  is  indeed  possible  to  measure  separately  the  portions  to  be 
deducted  from  the  external  conjugate  at  its  anterior  and  posterior 
parts  by  placing  one  arm  of  the  callipers  inside  the  vagina,  and 
the  other  outside  the  body,  and  then  get  the  true  internal  conju- 
gate by  deducting  these  from  the  external  conjugate.  This  can 
be  done  tolerably  well  in  some  cases  to  obtain  the  thickness  of 
the  sacrum  and  soft  parts  covering  it.  But  it  is  scarcely  possible 
to  get  the  internal  arm  of  the  callipers  sufficiently  high  on  the 
internal  surface  of  the  symphysis  pubis  to  measure  the  thickness 
of  the  anterior  pelvic  wall  with  accuracy.  This  method,  therefore, 
probably  does  not  give  the  true  conjugate  with  so  great  accuracy 
as.  that  of  deducting  it  from  the  diagonal  conjugate,  measured 
internally.  If  the  method  is  used,  the  callipers  should  have  one 
arm  curved,  as  in  Fig.  346,  p.  701,  the  other  straight  or  nearly 
straight.  The  curved  arm  should  be  introduced  into  the  vagina 
to  place  against  the  promontory  of  the  sacrum,  the  straight  arm 
to  measure  the  thickness  of  the  pubes. 

When  a  transverse  contraction  or  asymmetry  of  the  pelvis  from 
want  of  development  of  both  or  of  one  wing  of  the  sacrum  is 
suspected,  the  transverse  distance  between  the  posterior  superior 
spines  of  tlie  ilia  is  a  measurement  of  some  value,  since  it  gives 


704  The   Practice  of   Midwifery. 


some   indication   whether   or   not  the    sacrum   is  narrower   than 
usual.     Its  average  magnitude  is  about  5  inches  (12*5  cm.). 

Certain  oblique  external  diameters  should  also  be  measured 
when  an  oblique  pelvis  is  suspected.  These  will  be  mentioned  in 
the  account  of  the  diagnosis  of  the  oblique  pelvis.  In  the  com- 
paratively rare  case  of  contraction  of  the  pelvic  outlet,  the  antero- 
posterior diameter  of  the  outlet  is  obtained  by  measurement  with 
the  index  finger,  introduced  into  the  vagina,  the  radial  border 
pressed  against  the  apex  of  the  pubic  arch.  It  is  measured  from 
the  apex  of  the  pubic  arch,  at  its  internal  surface,  to  the  tip  of 
the  sacrum,  not  to  the  tip  of  the  coccyx,  unless  that  bone  is 
anchylosed  to  the  sacrum.  It  may  also  be  measured  by  callipers, 
one  point  being  placed  on  the  apex  of  the  pubic  arch  and  the  other 
on  the  posterior  surface  of  the  lower  extremity  of  the  sacrum ;  the 
deduction  of  1'5  cm.  will  give  the  true  measurement.  More 
important  than  this  is  the  so-called  posterior  sagittal  diameter  of 
the  outlet,  which  is  measured  from  the  centre  of  the  transverse  line 
joining  the  two  ischial  tuberosities  to  the  lower  end  of  the  sacrum 
(see  p.  784).  The  transverse  diameter  is  measured  between 
the  internal  margins  of  the  tubera  ischii.  It  may  be  measured 
either  by  callipers  or  by  a  straight  rule,  the  patient  being  placed  on 
her  back  or  on  her  side.  The  average  normal  magnitude  of  the 
former  diameter  is  about  4|  inches  (10'7  cm.),  of  the  latter  about 
4J  inches  (10*35  cm.). 

External  examination  also  reveals,  apart  from  the  measure- 
ments, certain  general  facts  about  the  pelvis,  such  as  the 
massiveness  of  the  bones,  development  of  prominences  for 
attachment  of  muscles,  direction  of  iliac  fossae,  whether  the  whole 
pelvis  is  symmetrical,  whether  the  spine  is  straight  and  the  legs 
equal,  and  whether  there  is  any  deviation  from  the  usual  position 
of  the  great  trochanters,  or  of  the  sacrum  in  relation  to  the 
innominate  bones. 

Internal  Measurements. — ^The  most  important  object  in  internal 
measurement  is  to  obtain  an  estimate  of  the  true  conjugate 
diameter,  since  this  is  the  diameter  of  the  pelvic  brim  which  is 
most  frequently  contracted,  and  the  contraction  of  which  has  the 
greatest  obstetric  importance.  By  the  term  true  conjugate  will 
be  here  understood  what  is  sometimes  called  the  obstetric  true 
conjugate,  namely,  the  line  drawn  from  the  promontory  of  the 
sacrum  to  the  nearest  point  on  the  inner  surface  near  the  top 
of  the  symphysis  pubis  (e  f.  Fig.  22,  p.  21),  not  the  line  from 
the  promontory  of    the  sacrum  to  the  centre  of  the  top   of   the 


Anomalies   of  the   Pelvis. 


705 


symphysis  pubis.     It  is  the  former  distance  alone  which  has  any 
practical  significance. 

The  distance  actually  measured  is  the  diagonal  conjugate  (b  n, 
Fig.  22,  p.  21),  or  sacro-subpubic  diameter.  From  this  the  true 
conjugate  has  to  be  inferred.  For  measurement  of  the  diagonal 
conjugate  the  patient  may  be  placed  on  the  left  side,  or  on  the 
back,  the  hips  raised  on  a  folded  blanket.  Two  fingers,  or  four 
fingers,  if  the  vagina  is  capacious  enough  to  allow  it,  as  in  the 


Fig,  347, — Measurement  of  diagonal  conjugate. 


first  stage  of  labour,  are  introduced  into  the  vagina  and  directed 
upwards  behind  the  cervix,  depressing  the  posterior  vaginal  cul-de- 
sac  until  the  tip  of  the  finger  touches  the  sacrum  (see  Fig.  347). 
The  fingers  are  then  still  raised  until  the  angle  formed  by  the 
promontory  of  the  sacrum  is  recognised  and  the  tip  of  the  middle 
finger  rested  upon  it.  For  this  the  fingers  have  to  be  directed 
nearly  vertically  upward  in  the  axis  of  the  trunk.  The  left 
hand  is  often  used  internally,  as  it  is  easier  to  mark  ofi^  with 
the  index  finger  of  the  right  hand  the  exact  spot  in  the  radial 
border  of  the  left  hand  corresponding  to  the  lower  border  of  the 
M.  45 


7o6  The  Practice  of   Midwifery. 

symphysis  pubis.  The  angle  the  diagonal  conjugate  makes  with 
the  vertical  axis  of  the  body  is  about  20°  in  the  normal  pelvis,  the 
pelvic  inclination  to  the  horizon  being  taken  as  55°.  If  the  pelvic 
inclination  is  greater,  and  the  promontory  of  the  sacrum  therefore 
higher,  as  it  sometimes  is  in  a  flattened  pelvis,  the  fingers  must  be 
directed  still  more  vertically  upwards.  Care  must  be  taken  not  to 
mistake  for  the  promontory  of  the  sacrum  a  slightly  projecting 
angle  which  sometimes  exists  between  the  first  and  second  sacral 
vertebrae.  The  tip  of  the  middle  finger  resting  then  upon  the 
promontory,  the  hand  is  slightly  raised,  so  as  to  press  the  radial 
side  of  the  index  finger,  or  the  side  of  the  hand,  against  the  apex 
of  the  pubic  arch.  The  point  of  contact  is  then  marked  with  the 
finger-nail  of  the  disengaged  hand,  the  hand  is  removed  from  the 
vagina,  the  finger-nail  being  kept  upon  it,  and  the  distance  from 
the  marked  point  diagonally  to  the  tip  of  the  middle  finger  measured 
with  a  rule.  This  gives  the  diagonal  conjugate.  It  is  rather 
difficult  to  mark  the  exact  point  with  the  nail  while  the  finger  is 
closely  pressed  against  the  pubic  arch.  It  is  still  better,  therefore, 
if  the  perceptive  faculty  of  the  radial  side  of  the  finger  can  be  so 
educated  that  it  retains  the  impression  of  the  exact  spot  cut  by  the 
apex  of  the  pubic  arch  until  the  hand  is  removed  from  the  vagina, 
and  the  finger-nail  is  then  placed  upon  this  spot.  If  there  is  any 
doubt  of  the  exact  point,  the  mean  should  be  taken  of  the  estimates 
derived  from  several  trials. 

In  the  normal  dry  pelvis  the  promontory  of  the  sacrum  can 
always  be  reached  in  this  way  with  two  fingers,  but  in  the 
living  woman  the  soft  parts  generally  prevent  it,  in  the  absence 
of  contraction,  unless  an  angesthetic  is  given.  As  a  general  rule, 
however,  if  the  fingers  can  be  introduced  a  fair  distance,  and 
the  promontory  cannot  be  reached,  it  may  be  inferred  that  there  is 
no  great  contraction  of  the  conjugate  diameter.  The  length  of  the 
fingers  must  of  course  be  taken  into  consideration.  In  a  flattened 
pelvis,  the  promontory  of  the  sacrum  can  often  be  felt  by  the 
index  finger  alone,  and  it  is  then  better  to  measure  the  diagonal 
conjugate  by  introducing  that  finger  only.  If  the  promontory 
can  be  easily  reached  in  this  way,  it  may  generally  be  inferred 
that  considerable  contraction  exists. 

The  diagonal  conjugate  (e  n,  Fig.  22,  p.  21)  being  known,  the 
true  conjugate,  or  the  side  e  f  of  the  triangle  e  f  n,  has  to  be 
deduced  from  the  two  sides  e  n,  n  f.  The  angle  e  f  n,  between 
the  symphysis  pubis  and  the  plane  of  the  brim,  is  almost  always 
an  obtuse  angle.  It  is  evident  that  the  difference  between  the  sides 
E  N  and  E  F  will  be  greater,  the  greater  is  the  side  f  n,  or  the 


Anomalies  of  the   Pelvis.  707 

height  of  the  symphysis  pubis,  and  the  greater  also  is  the  angle 
E  F  N,  or  the  inclination  of  the  symphysis  to  the  plane  of  the 
brim.  The  average  amount  to  be  deducted  from  the  diagonal 
conjugate  to  get  the  obstetric  true  conjugate  is  about  two-thirds 
of  an  inch.  Corrections  for  individual  cases  cannot  be  made  with 
absolute  exactness,  but  a  general  estimate  may  be  formed.  The 
height  of  the  symphysis  may  be  directly  measured.  If  it 
amounts  to,  or  exceeds,  an  inch  and  a  half,  the  inclination  of 
the  symphysis  being  assumed  normal,  the  deduction  may  be 
estimated  at  f  inch  at  least,  instead  of  §  inch.  Some  increase  in 
the  deduction  must  also  be  made  if  it  is  judged  that  the  pro- 
montory stands  higher  than  usual,  or  that  the  direction  of  the 
symphysis  pubis  is  more  vertical  than  usual.     In  the  reverse  cases 


B 

Fig.  348. — Diagram  for  calculation  of  true  conjugate  diameter. 

a  deduction  of  f  inch  may  be  rather  too  much,  the  difference 
being  sometimes  under  J  inch.  The  difference  is  likely  to 
be  greatest  in  the  case  of  a  very  greatly  flattened  pelvis  with 
excessive  pelvic  inclination.  It  may  then  reach  and  even  exceed 
1  inch.^ 

Direct  Measurement  of  True  Conjugate. — The  true  conjugate 
itself  can  be  directly  measured  by  two  methods,  which  are  of  great 
value,  but  can  only  be   applied  under  exceptional  circumstances. 

1  The  following  construction  gives  a  more  exact  result  (see  Fig.  348).  Draw 
a  line  A  B  equal  to  the  height  of  the  symphysis  pubis.  From  the  point  A  draw  A  c, 
making  an  angle  of  110''  with  A  B.  From  the  centre  B,  draw  a  circle  having  a  radius 
equal  to  the  length  of  the  diagonal  conjugate,  cutting  the  line  A  C  in  the  point  F.  The 
length  A  p  will  be  the  true  conjugate.  For  this  construction,  a  graduated  circle  is 
required  ;  or  the  angle  BAG  may  be  traced  from  Fig.  348.  The  only  element  of 
uncertainty  is  the  magnitude  of  the  angle  BAG,  which  varies  somewhat  in  different 
cases,  bat  its  average  magnitude  is  about  110°.  In  the  rachitic  pelvis,  it  is  often  rather 
less,  owing  to  the  diminished  pelvic  inclination,  and  may  be  taken  as  100°  on  an 
average. 

45—2 


7o8  The   Practice  of   Midwifery. 

The  first  method  (Hardie's)  is,  just  after  deHvery,  to  pass  the  whole 
hand  mto  the  pelvis  within  the  cervix,  and  see  how  far  the  four 
fingers  side  by  side,  or  the  breadth  of  the  hand,  will  pass  up  in  the 
conjugate  diameter.  The  point  at  which  they  are  arrested  is  noted, 
the  hand  withdrawn,  and  its  breadth  at  that  point  measured  with 
a  rule.  In  case  of  slight  contraction  only,  the  thumb  may  be 
added,  but  diameters  up  to  3J  inches  can  generally  be  measured 
without  it.  It  is  not  so  well  to  measure  the  diameter  by  separating 
the  fingers,  for  it  is  difficult  then  to  keep  them  in  exactly  the 
same  position  during  withdrawal.  This  method  gives  precisely 
the  conjugate  diameter  available  for  the  passage  of  the  foetus ; 
and  this  may  be  recorded  for  use  in  future  pregnancies. 

External  Measurement  of  True  Conjugate. — Another  method 
(Johnson's^)  is  by  measurement  from  outside  ;  and  this  can  be  used 
only  when  the  patient  is  not  pregnant,  the  abdominal  walls  not  too 
thick,  and  the  abdomen  not  very  tense.  The  index  finger  is  pressed 
in  above  the  pubes,  and  the  abdominal  wall  carried  before  it,  until 
it  rests  on  the  promontory  of  the  sacrum  (at  e.  Fig.  22,  p.  21). 
The  wrist  is  then  depressed,  and  the  point  noted  where  the  top  of 
the  symphysis  cuts  the  finger.  This  gives  the  distance  from  the 
promontory  to  the  centre  of  the  top  of  the  symphysis.  Something 
has  to  be  added  to  the  distance  measured  for  the  thickness  of  the 
soft  parts  pushed  before  the  finger,  and  something  subtracted  for 
the  thickness  of  the  pubes,  to  get  the  obstetric  true  conjugate  e  f. 
The  addition  and  subtraction  will  nearly  balance  when  the 
abdominal  walls  are  thin. 

Other  Results  of  Internal  Measurement.  —  The  true  conjugate 
diameter  is  the  only  dimension  of  the  brim  which  can  be  estimated 
at  all  accurately  from  internal  examination.  A  general  estimate, 
however,  can  be  obtained  of  the  characters  of  the  pelvis  in  many 
other  respects ;  and  it  is  in  forming  this  estimate  that  the 
experience  and  judgment  of  the  observer  are  of  most  value.  The 
student,  therefore,  in  every  case  of  labour,  as  well  as  in  vaginal 
examinations  apart  from  labour,  should  take  the  opportunity  of 
gaining  practice  in  judging  the  usual  pelvic  dimensions.  The 
chief  points  to  be  noted  are  the  following : — Whether  the  promon- 
tory of  the  sacrum  is  exactly  opi^osite  the  symphysis  pubis  ; 
whether  it  forms  a  jDrojection  encroaching  on  the  space  of  the 
pelvic  brim,  with  hollows  at  each  side  of  it,  as  in  the  reniform 
pelvis,  or  only  forms  a  part  of  a  concave  or  flattened  wall ;  whether 
there  is  ample  space  in  the  hollow  of  the  sacrum,  or  whether  the 

1  R.  W.  Johnson,  A  System  of  Midwifery,  London,  1769. 


Anomalies  of  the   Pelvis.  709 

sacrum  is  so  flattened,  without  being  divergent  from  the  symphysis 
pubis,  that  lower  diameters,  as  well  as  the  conjugate  of  the  brim, 
are  likely  to  cause  obstruction ;  whether  the  lateral  space  in  the 
pelvis  appears  to  be  as  large  as  usual ;  and  whether  the  space  is 
equal  on  the  two  sides  of  the  promontory  of  the  sacrum. 

The  measurement  of  the  diagonal  conjugate  can  be  made  in 
pregnancy,  or  even  in  labour,  if  the  head  is  still  high  in  the  pelvis, 
or  if  it  is  so  movable  that  it  can  be  pushed  up.  If  the  head 
has  descended  considerably  into  the  brim,  and  is  fixed  there,  even 
though  its  largest  diameters  may  not  yet  have  entered  the  brim, 
it  may  be  impossible  to  measure  the  diagonal  conjugate.  It  may 
still  be  possible,  however,  to  ascertain  whether  the  promontory 
of  the  sacrum  encroaches  upon  the  space  of  the  brim  or  not,  and 
to  form  an  estimate  as  to  the  symmetry  of  the  pelvis,  and  the 
lateral  space  in  it. 

It  must  always  be  borne  in  mind,  especially  in  considering  the 
treatment  of  contracted  pelves,  that  even  more  important  than  the 
exact  measurement  of  the  diameters  of  the  pelvis  is  the  estimation 
of  the  relation  the  size  of  the  fcetal  head  bears  to  the  size  of  the 
pelvis. 

Numerous  methods  and  instruments  have  been  devised  from 
time  to  time  for  the  purpose  of  measuring  the  foetal  head  in  utero. 
None  of  them  have,  however,  come  into  general  use,  as  the  results 
obtained  are  either  too  inaccurate  or  their  employment  too  difficult 
or  too  painful  to  render  them  of  practical  value.  The  best  clinical 
method  of  determining  the  relation  between  the  size  of  the  foetal  head, 
and  that  of  the  pelvis  is  the  one  introduced  by  Miiller^  in  1885.  In 
this  procedure  the  foetal  head  is  pressed  into  the  pelvic  brim  either 
by  the  examiner  himself  or  with  the  aid  of  an  assistant,  while, 
with  the  fingers  of  the  other  hand  introduced  into  the  vagina,  the 
degree  to  which  the  head  descends  into  the  pelvic  brim  is  estimated, 
and  also  the  amount  of  space  which  is  available  in  relation  to  the 
size  of  the  head.  In  an  intolerant  patient  it  may  be  necessary  to 
administer  an  ansesthetic,  and  if  the  slight  modification  suggested 
by  Munro  Kerr^  be  adopted,  and  while  the  index  finger  is  introduced 
into  the  vagina  the  thumb  is  placed  externally  over  the  symphysis 
pubis,  it  is  possible  to  determine  with  great  accuracy  the  amount 
of  overlapping  of  the  pelvic  brim  by  the  head  in  cases  where  it 
does  not  descend  into  the  cavity  of  the  pelvis.  This  method  is  of 
the  greatest  possible  value  not  only  in  determining  the  correct 
time  at  which  to   induce  premature  labour,  but   in  coming  to  a 

1   i'.  Miiller,  Sairimlung  Klin.  Vortrage,  1885,  No.  264. 

■-'  .Muiiro  Kerr,  Jouni.  (Jbst.  and  Gyn.  Brit.  Emp.,  I'JOiJ,  Vol.  111.,  iNo.  4,  p  341. 


7IO  The   Practice  of   Midwifery. 

decision  as  to  the  best  method  of  treating  a  case  of  contracted 
pelvis,  since  the  relation  of  the  size  of  the  head  to  that  of  the  pelvis 
is  the  most  important  factor  in  forming  a  correct  judgment  upon 
this  point. 

The  X-rays  in  the  Diagnosis  of  Contracted  Pelves. — Obstetricians 
have  attempted  from  time  to  time  to  make  use  of  the  X-rays  in 
determining  the  shape  and  size  of  the  pelvis,  but  unfortunately 
with  little  success.  There  are  several  difficulties,  the  chief  of  which 
are  that  it  is  impossible  to  place  the  plate  parallel  to  the  plane  of 
the  pelvic  brim,  or  always  at  the  same  distance  from  it.  For  these 
two  reasons  the  results  obtained,  although  they  give  a  very  fair  idea  of 
the  shape  of  the  pelvis,  yet  are  of  no  value  for  determining  its  exact 
measurements.  Various  ingenious  methods  have  been  devised  for 
overcoming  these  drawbacks,  but  none  of  them  are  sufficiently 
simple  or  accurate  to  render  them  of  clinical  value. 

Varieties  of  Contracted  Pelves. 

Classification. — Most  writers  on  the  subject  have  formulated 
some  scheme  of  classification  of  contracted  pelves.  One  of  the  best 
and  simplest  is  that  of  Schauta,^  who  divides  deformed  pelves  into 
five  main  classes,  dej)ending  upon  their  causation. 

Class  1. — Pelves  abnormal  as  the  result  of  faults  of  development. 

Generally  contracted  pelvis,  including  the  infantile,  the  masculine, 

and  the  dwarf. 
Simple  flat,  non-rickety  pelvis. 
Generally  contracted,  flat,  non-rickety  pelvis. 
Narrow,  funnel-shaj)ed  pelvis. 
Naegele  oblique  pelvis. 
Eobert  pelvis. 
Justo  major  pelvis. 
Split  pelvis. 

Class  2. — Pelves  abnormal  as  the  result  of  disease  of  the  ijelvic  bones. 
Eickety. 
Osteomalacic. 
New  growths. 
Fracture. 
Atrophy  caries. 

1  Schauta,  Die  Beckenanomalien  ;  P.  Miiller,  Handbucli  der  Gebuitshlilfe,  1889 
Bd.  2. 


Anomalies  of  the  Pelvis.  711 

Class  3. — Pelves  abnormal  as  the  result  of  disease  of  the 
sjnnal  column. 
Spondylolisthesis. 
Kyphosis. 
Scoliosis. 
Kypho-scoliosis. 
Assimilation. 

Class  4. — Ahnoriiialities  of  the  articulations  of  the  hones  of  the  pelvis. 

Synostosis — 

Of  the  symphysis  pubis  ; 

Of  the  sacro-ihac  articulations  ; 

Of  the  sacrum  with  the  coccyx. 
Imperfect  union  or  separation — 

Of  the  pelvic  articulations  ; 

Of  the  sacrum  with  the  coccyx. 

Class  5. — Pelves  abnormal  as  tJte  result  of  disease  of  the  lotver  limbs. 

Coxitis. 

Dislocation  of  one  or  both  hip  joints. 

Single  or  double  club-foot. 

Absence  or  curvature  of  one  or  both  lower  extremities. 

The  different  forms  of  contracted  pelvis,  however,  will  here  be 
classified  primarily  according  to  their  shape  rather  than  according 
to  their  causation,  since  it  is  the  shape  which  is  of  main  obstetric 
importance.  It  is  true  that  each  of  the  characteristic  shapes  has  a 
special  cause  to  which  it  is  most  frequently  due,  but  the  two  methods 
of  classification  do  not  give  exactly  parallel  results. 

There  are  three  forms  of  contracted  pelvis,  which  are  met  with 
more  frequently  than  the  others,  and  are  those  which  most  usually 
demand  operative  interference.  These  are  the  generally  contracted 
pelvis,  including  the  allied  varieties  of  the  infantile,  the  dwarf,  and 
the  masculine  pelvis,  the  pelvis  flattened  without  general  contraction 
and  the  generally  contracted  flattened  pelvis. 

The  Generally  Contracted  Pelvis. 

The  generally  contracted  pelvis,  or  pelvis  (equahiliter  justo  minor, 
is  the  rarest  of  the  three  principal  forms  mentioned  above.  It  is 
characterized  by  a  general  diminution  of  all  the  diameters,  but  no 
deviation,  or  but  little  deviation,  from  their  relative  proportion  in 
the  normal  pelvis.  In  its  most  perfect  form  it  is  seen  in  the  pelvis 
of  women  who  are  very  small,  or  actual  dwarfs,  but  not  otherwise 


712 


The  Practice  of   Midwifery. 


deformed.     The  pelvis  may  then  have  the  perfect  female  type,  but 
in  the  case  of  true  dwarfs,  the  parts  of  the  pelvis  may  be  found 


Fig.  349. — Sagittal  section  of  a  normal  pelvis. 

united,  not  by  bone,  but  by  cartilage  only,  as  in  childhood.  In 
most  cases,  hoAvever,  a  pelvis  which,  from  its  general  appearance, 
is  classed   as   a   generally  contracted   pelvis  is  found,  on  minute 


Fig.  350. — Sagittal  section  of  a  small  round  pelvis. 

examination,  to  deviate  slightly  from  the  normal  shape.     Sometimes 
the  conjugate  diameter  is  contracted  in  rather  greater  proportion 


Anomalies  of  the   Pelvis. 


713 


than  the  rest,  especially  when  rickets  has  existed  as  a  cause.  This 
kind  of  pelvis  forms  a  transition  towards  the  generally  contracted 
flattened  pelvis,  and  all  grades  between  the  two  may  exist. 

The  Infantile  Pelvis.— In  the  majority  of  pelves  approximating 
to  the  type  of  the  generally  contracted  pelvis,  the  characters  point 
to  a  partial  arrest  of  development,  the  changes  which  take  place  in 
the  advance  from  the  foetal  to  the  adult  pelvis  not  having  taken 
place  to  the  full  extent.  Thus  the  sacrum  is  relatively  narrow,  its 
curvature  on  transverse  section  is  too  great,  on  antero-posterior 
section  too  little,  its  face  does  not  look  enough  downward,  its 
posterior  surface  is  not  sufficiently  sunk  between  the  ilia,  nor  the 
whole  bone  in  the  direction  of  the  coccyx ;  the  pubic  arch  is  not 
fully  expanded;  the  transverse  diameter  of  the  brim  does  not 
exceed  the  conjugate  in  the 
due  proportion.  When  these 
peculiarities  are  well  marked, 
the  pelvis  is  called  infantile. 
The  general  size  of  the  out- 
let is  apt  to  be  small,  funnel- 
shaped,  compared  with  that 
of  the  inlet,  as  it  is  in  the 
fcetal  or  child's  pelvis.  But, 
as  already  explained  (see 
p.  26),  as  regards  the  shaj)e 
of  the  brim  at  any  rate,  the 
pelvis  would  be  more  pro- 
perly   called     childish     than 

infantile.  Fig.  351  should  be  compared  with  the  infant's  pelvis 
Fig.  23,  p.  24. 

The  generally  contracted  or  infantile  pelvis  may  arise  from  any 
disease  or  other  condition  which  interferes  with  nutrition  in  child- 
hood. Thus  it  may  be  the  result  of  scrofula,  cretinism,  premature 
hard  work,  or  bad  feeding.  It  is  interesting  to  note  that  this  variety 
of  pelvis  was  found  by  Whitridge  Williams  to  occur  in  two-thirds  of 
the  cases  of  contracted  pelves  in  black  women  in  Baltimore,  as  com- 
pared with  its  occurrence  in  one-third  of  the  cases  of  contracted 
pelves  in  white  women.  He  regards  it  as  a  result  of  the  imperfect 
physical  development  of  the  negroes  living  in  large  cities.  It  may 
also  arise  from  a  form  of  rickets,  protracted  in  time  but  not  severe 
in  degree,  so  that  it  has  the  effect  of  interfering  with  bone  growth, 
without  causing  actual  softening  of  the  pelvic  bones.  A  marked 
form  of  infantile  pelvis,  with  narrow  pubic  arch,  and  relatively 


Fig.  351. — Infantile  pelvis. 


714  The   Practice  of   Midwifery. 

small  transverse  diameter,  is  associated  with  congenital  absence  of 
the  uterus,  or  uterus  and  ovaries,  but  this  is  not  of  obstetric 
interest.  It  appears,  however,  that  an  infantile  pelvis,  though 
not  so  marked,  may  also  be  associated  with  that  minor  degree  of 
imperfect  development  of  uterus  and  ovaries,  in  which  menstrua- 
tion is  scanty,  and  begins  late  in  life,  the  cervix  uteri  is  conical 
and  narrow,  the  uterus  often  more  anteflexed  than  usual,  and  the 
woman  often  sterile.  Dr.  Eoper  has  related  such  a  case,  in  which 
pregnancy  followed  incision  of  the  cervix  uteri,  but  delivery  could 
only  be  effected  with  much  difficulty.  It  has  been  supposed  that  in 
some  cases  a  generally  contracted  pelvis  is  due  to  premature  bony 
union  of  the  parts  of  the  pelvis,  possibly  the  result  of  excessive 
muscular  work  in  early  life.  In  other  cases  no  cause  for  the 
infantile  form  of  pelvis  can  be  discovered,  and  it  must  be  ascribed 
to  some  unknown  congenital  tendency,  hereditary  or  otherwise. 
In  some  cases  an  infantile  shape  of  pelvis  is  associated  with  a  size 
not  below  normal,  growth  having  gone  on,  though  development  has 
failed. 

The  Rachitic  generally  Contracted  Pelvis. — It  has  been 
already  mentioned  that  a  simj)ly  infantile  pelvis  may  result  from 
a  form  of  rickets  which  only  impedes  bony  growth  without 
causing  softening  of  the  pelvis.  There  is  also  another  form  of 
generally  contracted  pelvis  due  to  rickets,  in  which  some  of  the 
changes  in  shaj)e  of  bones  due  to  that  disease  are  manifested. 
The  iliac  fossae  look  forward,  the  relation  between  the  Dist.  Sp.  II. 
and  Dist.  Cr.  II.  is  altered,  the  latter  not  exceeding  the  former  by 
the  usual  proportion,  and  there  are  signs  of  rickets  in  other  bones, 
as  in  the  tibite,  but  the  pelvis  is  not  flattened.  This  form  of  pelvis 
is  generally  described  as  due  to  the  disease  occurring  compara- 
tively late  in  childhood,  after  the  child  has  begun  to  walk,  the 
tendency  to  widening  and  flattening  being  in  consequence  counter- 
acted by  the  inward  thrust  at  the  acetabula.  It  must,  however, 
be  also  true  that  the  disease  has  been  so  far  mild  in  degree,  that 
neither  the  sacrum  nor  the  iliac  beams  are  sufiiciently  softened 
to  bend.  This  form  of  pelvis  is  therefore  to  be  contrasted  with 
the  triradiate  or  pseudomalacosteon  form  of  rachitic  pelvis  (see 
Chapter  XXX.),  in  which  also  the  disease  produces  its  effects  after 
the  child  has  learned  to  walk,  but  in  which  the  degree  of  softening 
is  greater  instead  of  less  than  that  which  leads  to  the  usual  flattened 
rachitic  pelvis. 

The  Masculine  Pelvis. — In  strong  muscular  women,  rather 
tall  in  proportion  to  their  breadth,  especially  those  who  have  a 


Anomalies  of  the   Pelvis.  715 

somewhat  masculine  appearance  from  the  growth  of  hah-  on  the 
face,  a  variety  of  uniformly  contracted  pelvis  is  sometimes  found, 
showing  some  approximation  toward  the  male  type.  The  bones 
are  thick,  the  pelvis  deep,  prominences  for  muscles  well  marked, 
the  transverse  diameter  too  small  in  proportion,  and  the  outlet 
comparatively  narrow. 

The  Dwarf  Pelvis. — Besides  the  true  dwarf  pelvis  characterised 
by  the  presence  of  cartilage  uniting  the  bones,  Breus  and  Kolisko 
recognise  the  cretin  dwarf  pelvis  and  the  hypoplastic  dwarf  pelvis. 
The  first,  with  its  poorly  developed  bones,  is  the  result  of  faulty 
growth  throughout  early  life,  while  the  second  is  a  normal  pelvis 
in  miniature,  but  is  completely  ossified. 

In  the  marked  cases  of  general  pelvic  contraction  all  the  internal 
diameters  of  the  pelvis  may  be  reduced  by  as  much  as  one-fourth 
of  their  normal  value.  The  difficulty  in  delivery  may  then  be  very 
considerable,  even  after  the  performance  of  craniotomy. 

Mechanism  of  Labour. — In  minor  degrees  of  contraction  the 
mechanism  of  labour  is  not  altered,  except  that  the  flexion  of  the 
head  is  apt  to  be  extreme  while  it  is  passing  through  the  brim,  after 
it  has  entered  the  cavity  of  the  pelvis,  owing  to  the  want  of  space 
for  its  longest  diameter,  and  that  the  natural  rotations  may  be 
impeded  by  excessive  friction. 

Diagnosis. — All  the  external  diameters  are  diminished  in  about 
equal  proportions,  and  the  diagonal  conjugate  is  also  diminished. 
On  internal  examination  there  is  found  to  be  diminution  of  lateral 
space,  but  no  encroachment  by  the  promontory  of  the  sacrum  into 
the  area  of  the  brim.  The  normal  relation  between  the  Dist.  Sp.  II. 
and  Dist.  Cr.  II.  is  unaltered,  except  in  the  rachitic  form  of  the 
generally  contracted  pelvis. 

The  Flattened  Pelvis  and  the  Generally  Contracted 
Flattened  Pelvis. 

In  the  former  class  of  pelvis  there  is  contraction  of  the  conjugate 
diameter,  but  no  notable  contraction  of  the  remaining  internal 
diameters.  In  the  latter,  combined  with  the  relative  contraction 
of  the  conjugate,  there  is  general  smallness  of  the  whole  pelvis 
from  failure  of  development.  It  is  evident  that  if  a  full-sized 
pelvis  were  flattened,  its  transverse  diameter  would  be  rendered 
greater  than  normal.  In  point  of  fact,  however,  it  is  hardly  ever 
found  that  the  transverse  diameter  is  greater  than  normal  in  a 


7i6 


The  Practice  of   Midwifery. 


flattened  pelvis,  and  frequently  it  is,  if  anything,  rather  diminished. 
Therefore,  even  in  pelves  reckoned  merely  as  flattened,  because 
there  is  no  notable  contraction  in  the  transverse  diameter,  there  is 
almost  always,  in  reality,  some  lack  of  full  development. 

The  flattened  pelvis,  whether  generally  contracted  or  not,  may 
be  divided  into  two  varieties,  according  to  the  shape  of  the  brim, 
the  elliptic  flattened  pelvis,  and  the  reniform  or  kidney -shaped 
flattened  pelvis.  In  the  former  the  shape  of  the  brim  resembles 
an  ellipse  flattened  on  the  posterior  side.  The  concavity  of  the 
sacrum  on  transverse  section  is  almost  or  entirely  lost,  but  is  not 


Fig.  352. — Section  of  a  normal  pelvis  parallel  to  and  just  below  the  inlet.^ 

converted  into  a  projection.  In  the  latter  the  brim  is  kidney- 
shaped  (see  Fig.  356,  p.  719).  The  promontory  of  the  sacrum 
has  sunk  so  far  inward  toward  the  brim  as  to  form  a  rounded 
prominence  encroaching  upon  its  area.  This  is  the  commoner 
variety  of  the  two. 

By  German  authors  a  different  division  of  flattened  pelves  is 
made,  namely,  into  the  rachitic  and  non-rachitic  flattened  pelves. 
It  is  admitted,  however,  that  the  form  called  non-rachitic,  because 
other  characteristic  peculiarities  of  rickets  are  absent,  is  often  due 

^  Breus  and  Kolisl-vO,  Die  Pathologischen  Beckenformen,  1904,  Bd.  1,  Th.  2,  Fig.  143. 


Anomalies   of  the   Pelvis. 


717 


to  slight  rickets.  Moreover  the  division  given  above  corresponds 
to  a  difference  in  the  mechanism  of  labour,  while  that  into  rachitic 
and  non-rachitic  forms  does  not. 

Causation, — The  flattened  pelvis  without  general  contraction  is 


Fig.  353. — Section  of  flattened  rachitic  pelvis  parallel  to  and  just  below  the  inlet.i 

probably  often  due  to  slight  rickets,  causing  some  softening  of  the 
sacrum,  but  not  marked  enough  to  produce  the  general  peculiarities 


Fig.  3.54. — Sagittal  section  of  a  rickety  flat  pelvis. 

due  to  the  disease.  The  fact  that  some  slight  failure  of  develop- 
ment almost  always  exists  is  in  favour  of  this  view.  The 
dofoDuity  is  also  ascribed  to  lifting  or   carrying  heavy  weights, 

I  Breus  and  Kolisko,  he.  cit.,  Bd.  1,  Th.  2,  Fig.  144. 


7i8 


The  Practice  of   Midwifery. 


such  as  babies,  in  childhood,  either  with  or  without  the  slight 
rachitic  tendency.  Flattening  is  also  produced  by  excess  in  the 
pelvic  inclination,  for  then  the  component  of  the  body- weight 
which  acts  in  the  plane  of  the  pelvic  brim  is  increased.  The 
excess  of  inclination  may  be  due  to  an  exaggeration  of  the  normal 
curves  of  the  spine,  a  condition  itself  often  the  consequence  either 
of  slight  rickets,  or  of  carrying  weights  in  childhood,  or  of  both 
causes  combined.  Whether  or  not  general  contraction  is  present, 
the  elliptic  flattened  shape  of  the  brim  must  be  ascribed  to  the 
effect  of  the  body-weight,  without  marked  softening  of  the  sacrum  ; 


Fig.  355. — Upper  half  of  a  section  parallel  to  the  plane  of  the  pelvic  inlet,  through  a 
normal  and  a  rachitic  innominate  bone,  showing  the  marked  shortening  and  the 
increased  curvature  of  the  iliac  portion  (1 — 2).i 

when  the  sacrum  is  much  softened  the  reniform  shape  is  produced. 
Hence,  as  a  general  rule,  the  greater  part  rickets  has  in  the 
causation,  the  more  marked  is  the  reniform  shape.  Sometimes, 
however,  a  distinctly  rachitic  pelvis,  with  general  contraction,  has 
the  simply  flattened  shape  either  because  the  softening  has  not 
specially  picked  out  the  sacrum,  or  because  the  disease  has  shown 
itself  more  in  arrest  of  development  than  in  softening.  The  simple 
flattening  in  such  a  case  may  have  been  produced  by  carrying 
weights.     The  degree  of   contraction   is  seldom  extreme  in  those 


1  Breus  and  Kolisko,  loc.  cit.,  Bd.  1,  Th.  2,  Fig.  128. 


Anomalies  of   the  Pelvis. 


719 


cases  where  its  rachitic  origin  is  not  manifested  by  the  peculiarities 
in  the  pelvis  generally  produced  by  that  disease,  the  conjugate 
diameter  being  rarely  less  than  3  inches. 

Breus  and  Kolisko^  lay  great  stress  upon  want  of  development 
of  the  bones  in  the  production  of  the  flat  pelvis.  They  maintain 
that  the  shortening  of  the  iliac  portion  of  the  innominate  bone  ^  is 
one  of  the  most  characteristic  signs  of  rickets,  and  that  it  is  the 
most  important  factor  in  the  production  of  the  flattening  of  the 
rickety  pelvis.  In  such  a  pelvis  the  shortening  of  this  portion  of 
the  bone  is  in  striking  contrast  to  the  slight  shortening  of  the  sacral 
portion,  and  to  the  practically  normal  length  of  the  pubic  portion. 

The  Rachitic  Flattened  Pelvis. —  This  is  the  most  typical  form  of 
rachitic  pelvis.     Usually  there  is  general  contraction  as  well  as 


Fig.  356. — Reniform  rachitic  pelvis. 


flattening,  in  consequence  of  the  retardation  of  development  pro- 
duced by  the  disease,  and,  in  the  higher  degrees  of  contraction, 
this  is  always  the  case.  The  bones  are  usually  small  and  thin, 
but  there  may  be  compensatory  hypertrophy  in  parts.  Thus  the 
thickness  of  the  sacrum  may  be  increased,  and  the  difference 
between  the  external  conjugate  and  true  conjugate  diameters 
therefore  greater  than  usual.  The  brim  has  the  reniform  more 
frequently  than  the  elliptic  shape,  owing  to  the  softening  of 
the  sacrum  itself  (Fig.  356).  In  the  rachitic  pelvis,  most  of 
the  changes  in  shape  which  occur  in  the  advance  from  the  fcetal 
to  the  adult  pelvis  from  mechanical  influences  are  exaggerated. 

1  Breus  and  Kolisko,  loc.  ait.,  Bd.  J,  Th.  2,  p.  45.5. 

2  The  iliac  portion  of  the  os  innominatum  corresponds  in  extent  to  the  iliac  portion 
of  the  ilio-pectineal  line  extending  from  the  anterior  margin  of  the  auricular  surface  to 
the  ilio-pectineal  eminence. 


720 


The   Practice  of   Midwifery. 


The  pubic  arch  is  more  widened,  the  relative  size  of  the  transverse 
diameter  of  the  brim,  and  of  the  distance  between  the  tubera 
ischii,  is  more  increased.  The  sacrum  sinks  more  deeply  between 
the  ilia  both  toward  the  brim  and  in  the  direction  of  the  coccyx, 
and  as  a  result  of  its  displacement  downwards  and  forwards  there 

is  a  deep  depression  over  the 
sacral  spines.  The  promontory 
is  more  rotated  forwards,  so  that 
the  anterior  surface  looks  more 
downwards,  and  the  curvature 
on  antero-posterior  section  is 
usually  increased,  but  in  some 
cases  the  bone  is  almost  straight 
on  vertical  section  (Fig.  360, 
p.  722).  The  curvature  on  trans- 
verse section  is  diminished  and 
generally  converted  into  a  con- 
vexity toward  the  brim. 

These  effects  are  due  to  the 
fact  that  the  bones  are  softened, 
but  not  so  much  so  as  to  prevent 
their  acting  as  beams  or  levers. 
The  softening  affects  chiefly  the 
growing  extremities  and  the  car- 
tilage about  to  form  bone,  so  that 
the  yielding  takes  place  mainly 
at  certain  points,  as  between  the 
centre  and  wings  of  the  sacrum. 
If  the  softening  is  more  extreme, 
affecting  the  whole  of  the  bones, 
so  that  they  can  no  longer  act  as 
levers,  a  totally  different  form  of 
pelvis,  resembling  that  of  mala- 
costeon,  is  produced  (see  Chap- 
ter XXX.),  the  acetabula  being 
pushed  inwards. 

The  relative  widenina;  of  the 


Fig.  357. — Skeleton  of  a  rachitic  dwarf 
with  contracted  pelvis. 


pelvis,  especially  at  the  outlet,  is  explained  by  the  fact  that  the 
effects  of  the  disease  on  the  pelvis  are  mainly  produced  before  the 
child  can  walk  or  stand  much,  and  that  therefore  the  counter- 
pressure  at  the  acetabula  has  little  influence.  The  widening  then 
is  chiefly  due  to  the  effect  of  the  body-weight  in  the  sitting  position 
calling  out  the  leverage  of  the  innominate  bones  (see  pp.  23 — 26), 


Anomalies  of  the  Pelvis.  721 

and  to  that  of  the  counter-pressure  on  the  tubera  ischii  in  rotating 
outward  the  lower  part  of  the  innominate  bones  (see  p.  26).  The 
bending  inward  of  the  lower  end  of  the  sacrum  so  as  to  increase 
the  curvature  of  the  bone  on  antero-posterior  section  is  partly  due 
to  the  resistance  of  the  sacro-sciatic  ligaments  to  the  rotation  for- 
wards of  the  promontory,  and  to  muscular  action,  but  is  assisted 
also  by  the  effect  of  the  pressure  on  the  lower  end  of  the  bone  in 
sitting  (Fig.  26). 

The  shape  of  the  iliac  fossae  is  characteristic,  and  has  been 
already  referred  to  as  valuable  in  diagnosis.  They  are  flatter 
than  usual,  and  look  more  forward,  so  that  the  maximum  distance 
between  the  crests  does  not  much  exceed  that  between  the  spines. 


Fig.  358. — The  outlet  of  a  rickety  flat  pelvis. 

In  cases  of  marked  deformity,  the  distance  between  the  spines 
is  the  widest  diameter.  This  shape  of  the  ilia  appears  to  be 
partly  due  to  arrested  development,  but  partly  also  to  the  action 
of  the  gluteal  muscles.  There  are  other  minor  points  by  which 
the  effect  of  rickets  is  shown,  such  as  eversion  of  the  edges 
of  bone  to  which  muscles  are  attached,  especially  those  of  the  pubic 
arch,  and  of  the  ischia,  and  sharpness  of  the  ilio-pectineal  line. 
Bony  projections  are  sometimes  present,  forming  the  so-called  pelvis 
spinosa. 

The  general  effect  is  to  produce  a  shallow  pelvis,  the  transverse 
diameter  of  the  brim  relatively  wide,  but  in  most  cases  absolutely 
more  or  less  below  the  normal,  the  outlet  less  contracted  than  the 
inlet  in  all  its  dimensions,  and  sometimes  even  actually  expanded. 
This  wideness  of  the  outlet  and  shallowness  of  the  pelvis  facilitates 

M.  46 


722 


The  Practice  of  Midwifery. 


the  access  to  the  foetus  in  the  case  of  difficult  delivery  after 
craniotomy.  The  promontory  of  the  sacrum  is  not  uncommonly 
displaced  somewhat  to  one  side  in  consequence  of  a  scoliosis 
(lateral  curvature)  of  the  spine.  The  pelvis  then  partakes  of  the 
characters  of  the  oblique  pelvis,  hereafter  to  be  described  (see 
Chapter  XXX.). 

In  some  instances  the  body  of  the  first  sacral  vertebra  is  dis- 
placed forwards  to  a  very  marked  degree,  and  its  lower  border  forms 
a  projection,  the  so-called  false  promontor3^  It  is  important  to 
recognise  such  a  condition  clinically,  as  the  distance  from  it  to  the 


Fig.  359. — Median  section  through  a  flat  rachitic  pelvis.  ^ 

upper  border  of  the  symphysis  pubis  may  be  the  shortest  antero- 
posterior diameter  of  the  brim. 

In  the  rachitic  pelvis  the  inclination  of  the  brim  to  the  horizon 
is  generally  somewhat  diminished.  This  may  be  explained  on 
two  grounds.  First,  on  account  of  the  sinking  of  the  sacrum 
deeper  toward  the  coccyx.  Secondly,  owing  to  the  sinking 
of  the  sacrum  into  the  brim,  the  line  of  action  of  the  body- 
weight  falls  anteriorly  to  the  sacro-iliac  joints.  The  counter- 
pressures  to  the  body-weight  therefore  at  the  acetabula  or  the 
tubera  ischii,  which  must  necessarily  act  in  the  same  transverse 
vertical  plane  as  the  body-weight  to  produce  equilibrium,  tend  to 
rotate  the  anterior  part  of  the  pelvis  upward  on  a  transverse  axis 
passing  through  the  sacro-iliac  joints.  Thus,  while  an  increase  of 
the  pelvic  inclination  in  any  pelvis  tends  to  cause  the  sacrum  to 

1  Breus  and  Kolisko,  loo.  cit.,  Bd.  1,  Th,  2,  Fig.  135. 


Anomalies  of  the  Pelvis. 


723 


sink  forwards  into  the  brim,  such  sinking  forwards  has  a  secondary- 
effect,  tending  to  diminish  the  pelvic  inclination.  There  is  often 
a  counterbalancing  influence,  tending  to  increase  the  pelvic 
inclination  in  the  rachitic  pelvis,  namely,  an  exaggeration  of  the 
normal  curves  of  the  spine.  But  the  influence  of  the  first  two 
causes  usually  preponderates. 

Figure-of-eight  Rachitic  Pelvis. — In  very  rare   cases  there  is  a 
depression  inwards  of  the  symphysis  pubis  of   a   rachitic  pelvis. 


^ 


!^  f 


Fig. 


360. — Median   section   through   a   fiat   rachitic   pelvis    with   marked 
bending  of  the  sacrum.  1 


This  is  ascribed  to  the  traction  of  the  recti  muscles  (see  Fig.  361, 
p.  724).  In  this  case  the  brim  has  the  shape  of  a  figure  of  eight, 
or  hour-glass,  but  not  a  uniform  figure  of  eight,  for  the  projection 
inwards  of  the  sacrum  is  greater  than  that  of  the  symphysis  pubis, 
and  the  hollows  at  each  side  of  it  deeper.  More  frequently  the 
symphysis  pubis  is  not  drawn  in,  but  the  curvature  near  that 
point  is  more  acute,  in  consequence  of  a  slight  flattening  opposite 
the  acetabula,  due  to  the  inward  thrust  of  the  femora.  The  pelvis 
thus  approximates  to  a  heart  shape  (see  Fig.  357,  p.  720).     Such  a 


1  Breus  and  Kolislio,  loo.  cit^  Bd.  1,  Th,  2,  Fig.  136. 


46—2 


724  The  Practice  of   Midwifery. 

pelvis  may  be  regarded  as  intermediate  between  the  ordinary 
reniform  shape  and  the  generally  contracted  rachitic  pelvis,  and  it 
implies  an  intermediate  influence  of  standing,  walking,  etc. 

Chondrodystrophic  Pelvis. — The  pelvis  due  to  chondrodystwphia 
fa'talis  or  enchondroplasia  (Fig.  362)  is  somewhat  allied  to  the 
reniform  type  of  rachitic  pelvis.  The  disease  as  it  occurs  in  foetal 
life  has  already  been  described  (see  p.  544).  If  the  subjects  of  it 
survive  to  maturity,  they  are  dwarfs  of  a  peculiar  appearance. 
The  trunk  may  be  of  not  much  less  than  normal  size,  but  the 
limbs  are  extremely  stunted ;  the  shortening  affecting  the  humerus 
and  femur  more  than  the  forearm  and  lower  leg.  There  is  some 
evidence  of  softening  of  bones  allied  to  that  which  occurs  in 
rickets,  for  the  lumbar  curve  is  generally  greater  than  normal, 
and  the  promontor}^  of  the  sacrum  projects  more  than  usual  into 


Fig.  361. — Figure-of-eight  rachitic  pelvis. 

the  brim  (Fig.  362).  The  iliac  fossfe  are  also  everted  as  in  rickets. 
The  pelvis  diflers  from  that  of  rickets,  in  that  its  contraction  is 
chiefly  due  to  shortening  of  that  part  of  the  ilium  which  forms  a 
part  of  the  ilio-pectineal  line.  Thus  the  acetabulum  is  much 
apj)roximated  to  the  sacro-iliac  synchondrosis,  and,  in  consequence, 
the  pubes  to  the  sacrum.  The  conjugate  diameter  is  therefore 
much  more  shortened  than  in  any  rachitic  pelvis,  except  the  most 
extreme  forms.  In  six  chondrodystrophic  pelves  described  by 
Breus  and  Kolisko,^  the  conjugate  varied  from  If  to  2|  inches 
(4  to  7  cm.).  In  most  cases,  therefore,  Caesarean  section  is  necessary 
for  delivery. 

Mechanism  of  Labour  in  the  Flattened  Pelvis.  — The 
flattened  pelvis  has  certain  peculiar  efl'ects  of  its  own  upon  the 
mechanism  of  labour.  In  accordance  with  the  three  dimensions 
of  the  foetal  head,  there  are  modifications  of  the  mode  in  which  the 

1  Loc.  cif.,  1900,  Bd,  1,  Th.  1,  pp.  313—349. 


Anomalies  of  the  Pelvis.  725 

head  passes  through  the  pelvis  in  three  respects :  (1)  as  to  its 
rotation ;  (2)  as  to  its  flexion  or  extension  ;  (3)  as  to  its  lateral 
obliquity  or  lateral  flexion. 

(1.)  Rotation. — In  pregnancy  the  head  will  generally  lie  with 
the  occijiut  somewhat  forward,  on  account  of  the  adaptation  of  the 
whole  foetus  to  the  shape  of  the  uterus  and  of  the  abdominal  cavity. 
But,  on  the  rupture  of  the  membranes,  the  head  will  enter  or 
attempt  to  enter  the  brim  with  its  antero- posterior  diameter  in  the 
longest  diameter  of  the  brim,  that  is  to  say,  in  nearly  a  transverse 
position,  whenever  the  space  is  not  sufficient  to  allow  it  to  enter 
freely  in  an  oblique  position.     In  the  elliptic  flattened  pelvis,  the 


Fig.  362. — Chondrodystrophic  pelvis  of  a  woman  twenty-seven  years  of  age.  i 

antero-posterior  diameter  of  the  head  will  be  almost  exactly  trans- 
verse. In  the  reniform  flattened  pelvis,  the  main  part  of  the  space 
at  the  sides  of  the  pelvis  is  posterior  to  a  transverse  line  bisecting 
the  conjugate  diameter.  Hence  the  broader  or  occipital  end  of  the 
head  will  find  most  space  by  turning  somewhat  backward  (see 
Fig.  363,  p.  726).  If  there  is  sufficient  transverse  space  in  the 
pelvis,  and  the  shape  is  reniform,  the  head  generally  deviates 
bodily  somewhat  toward  that  side  of  the  pelvis  toward  which  the 
occiput  is  directed,  so  as  to  bring  the  broad  biparietal  diameter 
into  the  freer  lateral  space,  and  get  a  smaller  diameter  of  the  head, 
one  as  near  as  possible  to  the  bitemporal,  into  opposition  to  the 
contracted  conjugate  diameter  (Fig.  363).  It  is  only  when  the 
head  is  very  small  relatively  to  the  transverse  diameter  of  the  pelvis 
tliat  it  can  deviate  so  far  to  one  side  as  to  allow  the  bitemporal 
diameter  itself  to  enter  the  conjugate.     Thus  at  the  early  stage  of 

>   Brcus  and  Kolisko,  h.c.  rit.,  V,<\.   \,  Th.  1,  Fig.  89,  p.  ■'Jl.'S. 


726 


The  Practice  of   Midwifery. 


labour  there  is  often  some  rotation  of  the  occiput  hackivards.  The 
antero-posterior  diameter  remains  in  the  same  direction  until  the 
superior  strait  is  passed.  Then,  if  flexion  occurs,  the  occiput  is 
rotated  forwards  as  usual  by  the  inclined  plane  of  soft  parts. 

(2.)  Flexion  and  Extension. — Before  labour  the  head  is  Ijdng 
above  the  brim,  if  contraction  is  at  all  considerable.  The  head 
not  entering  the  brim  easily,  both  occiput  and  forehead  are 
detained  above  its  level,  and  therefore  the  usual  flexion  cannot 
take  place.  Owing  to  the  shape  of  the  head,  the  anterior  fon- 
tanelle  will  be  more  within  reach  than  the  posterior.  The  head 
at  this  stage  is  therefore  more  extended  than  usual.  The  further 
course  of  affairs  depends  upon  the  exact  shape  and  size  of  the 
pelvis,  and  the  relation  of  these  to  the  size  and  shape  of  the  head, 
especially  as  regards  the  prominence  of  the  parietal  tubera.      In 


Fig.  363. — Engagement  of  head  in  brim  of  flattened  pelvis  viewed  from  below 
in  the  axis  of  the  brim  : — a,  anterior  fontanelle  ;  h,  sagittal  suture  ;  c,  pos- 
terior fontanelle  ;  d,  promontory  of  sacrum  ;  e,  symphysis  pubis. 

the  reniform  pelvis,  when  the  lateral  spaces  are  large,  as  in  the 
case  of  the  flattened  pelvis  \Yithout  any,  or  with  only  a  slight 
degree  of,  general  contraction,  it  generally  happens  that  when  the 
head  is  beginning  to  engage  in  the  brim,  the  diameter  most 
tightly  grijjped  is  that  opposed  to  the  contracted  conjugate.  The 
biparietal  diameter  in  the  free  sjjace  at  the  side  meets  with  less 
resistance.  The  greatest  resistance  is  then  anterior  to  the  occipital 
condyles,  and  therefore  produces  flexion,  the  head  rotating  in 
some  measure  around  the  diameter  gripped  in  the  conjugate  until 
the  occiput  is  well  engaged  in  the  pelvis.  In  this  case,  therefore, 
the  head  passes  the  brim,  if  able  to  pass  it  at  all,  by  a  movement 
of  flexion. 

The  mechanism  is  different  in  the  case  of  the  elliptic  flattened 
pelvis,  and  also  in  some  cases  of  the  reniform  pelvis,  when  the 
reniform  shape  is  slightly  marked,  and  the  hollows  at  each  side  of 
the  promontory  not  large.     The  diameter  which  meets  with  most 


Anomalies  of  the  Pelvis.  727 

resistance  is  then  frequently  the  biparietal,  that  which  is  engaged 
in  the  conjugate  not  fitting  so  tightly.  The  points  of  greatest 
resistance  are  then  behind  the  line  of  propelling  force  passing 
through  the  condyles,  and  therefore  the  resistance  produces 
extension.  The  head  then  passes  through  the  brim,  if  able  to 
pass,  in  a  position  of  somewhat  greater  extension  than  it  had 
while  resting  above  the  brim.  There  is  sometimes  evidence  of 
this  in  a  groove  of  depression  on  the  parietal  bone  caused  by  the 
pressure  of  the  promontory  as  the  head  passes.  When  the  passage 
takes  place  in  the  position  of  extension,  this  groove  runs  nearly 
parallel  to  the  coronal  suture  and  posterior  to  it.  Otherwise  it 
is  obliquely  inclined  towards,  or  crosses,  the  coronal  suture.  It 
is  obvious  that  it  must  depend  greatly  upon  the  relative  size  of 
the  biparietal  diameter,  and  the  degree  to  which  it  can  be 
diminished  by  moulding,  whether  the  biparietal  diameter  or  that 
engaged  in  the  conjugate  meets  the  most  obstruction.  These  vary 
greatly  in  different  heads. -"^ 

The  extension  of  the  head  is  generally  limited  by  the  capacity  of 
the  transverse  diameter  of  the  pelvis  to  admit  the  long  diameter  of 
the  head  when  increased  by  extension.  In  a  generally  contracted 
flattened  pelvis,  which  is  not  wide  enough  to  admit  the  long 
diameter  unless  the  head  is  flexed,  the  head  must  either  pass  by 
the  movement  of  flexion,  or  else  remain  arrested. 

After  the  head  has  passed  the  brim,  flexion  is  usually  produced 
by  the  resistance  of  the  soft  parts,  and  the  occiput  rotates  forwards 
in  the  usual  way. 

(3.)  Lateral  or  Biparietal  Obliquity. — In  a  fcetal  head  before 
moulding,  the  biparietal  diameter  is  generally  greater  than  adjacent 
oblique  diameters  drawn  from  a  point  a  little  above  the  parietal 
tuber  on  one  side  to  a  point  a  little  below  it  on  the  other  (which 
may  be  called  subparieto-superparietal  diameters).  The  same  is 
true,  though  to  a  less  degree,  of  the  maximum  transverse  diameter 
in  other  parallel  sections  of  the  head.  Hence  the  head  will  pass 
through  a  smaller  space  if  tilted  a  little  sideways,  so  that  one 
parietal  tuber  passes  in  advance  of  the  other.  Now,  if  a  body  is 
pushed  through  a  narrow  passage  by  its  posterior  pole,  and  is  so 
shaped  that  a  tilting  one  way  or  other  will  facilitate  its  passage,  the 
resistances  are  certain  to  effect  that  tilting.  The  body  is  in  unstable 
equilibrium  until  the  tilting  is  produced,  and  the  slightest  variation 
in  the  direction  of  the  propelling  force  or  the  amount  of  friction 


1  By  Litzmann,  Playfair,  Spiegelberg,  and  Lusk  only  the  former  of  these  modes  of 
transit,  by  Schrrider  and  Ooodcll  only  the  latter,  is  described  as  being  the  usual  one 
in  the  flattened  pelvis. 


728  The  Practice  of   Midwifery. 

will  bring  it  about.  The  principle  may  be  illustrated  by  the  experi- 
ment of  trying  to  push  an  egg  through  an  elastic  tube  with  its  long 
diameter  exactly  across  the  axis  of  the  tube.  The  egg  is  certain  to 
turn  so  as  to  bring  its  shorter  diameters  into  coincidence  with  the 
diameters  of  the  tube.  Similarly  the  head  can  never  by  any 
possibility  continue  to  advance  in  a  position  of  brow  presentation, 
with  its  longest  mento-occipital  diameter  thrown  across  the 
parturient  canal,  but,  if  it  advances  at  all,  the  presentation  is 
always  converted  into  either  a  face  or  a  vertex  (see  p.  339).  It 
is  in  the  same  way  that  lateral  tilting  of  the  head  is  produced  by 
the  resistances  whenever  there  is  pressure  at  the  ends  of  lateral 
diameters,  and  a  mechanical  advantage  is  thus  to  be  gained. 

It  may  also  be  shown  that  the  shape  of  the  head  is  such  that, 
if  arrested  above  the  brim,  it  is  in  a  position  of  unstable  equili- 
brium until  it  has  been  tilted  to  one  side  or  other  to  a  greater 
degree  than  that  which  will  give  the  greatest  mechanical  advan- 
tage when  the  biparietal  diameter  is  actually  engaging  in  the  brim. 
When  the  head  is  engaging  in  the  pelvis,  the  greatest  mechanical 
advantage  is  gained  by  a  tilting  of  not  more  than  about  12°  or  15°, 
even  before  moulding.  When  the  head  is  arrested  above  the  brim, 
the  tilting  may  proceed  to  as  much  as  20°  or  25°,  though  such  an 
amount  of  obliquity  is  not  a  mechanical  advantage,  but  rather  the 
contrary. 

In  the  flattened  pelvis,  it  is  found  that  the  sagittal  suture  is 
generall}^  displaced  towards  the  promontory  of  the  sacrum,  so 
that  the  anterior  parietal  bone  enters  the  brim  in  advance  of  the 
posterior,  and  the  child's  head  is  flexed  towards  its  posterior 
shoulder  (Fig.  176,  p.  266),  {anterior  parietal  presentation) . 

This  is  called  Naegele-obliquity,  because  Naegele  described  it  as 
existing  in  normal  labour.  It  remains  to  explain  why  the  tilting 
is  generally  in  this  direction  rather  than  the  opposite.^ 

One  reason  may  be  posterior  obliquity  of  the  uterus  in  reference 
to  the  axis  of  the  brim.  Frozen  sections  show  such  an  obliquity, 
and  K.  Barnes  contends  that  it  is  the  normal  condition.  In  frozen 
sections,  however,  it  is  due,  in  great  measure,  to  the  prolonged 
effect  of  gravity  on  the  corpse  lying  on  its  back,  and  to  the  chest 
being  in  a  position  of  exj)iration,  whereas  in  a  pain  it  is  in  one  of 
deep  inspiration.  It  is  probable,  therefore,  that  the  usual  assumj)- 
tion  that  the  axis  of  the  parturient  uterus  normally  coincides  with 
that  of  the  brim  is  not  far  from  the  truth.     But  the  slightest  degree 

^  See  papers  by  the  author  "  On  the  Occurrence  in  Normal  Labour  of  Lateral 
Obliquity  of  the  Fcetal  Head,"  Trans.  Obstet.  Soc,  London,  Vol.  XVII. ,  187.5,  p.  283  ; 
and  by  Robert  Barnes  "  On  the  Mechanism  of  Labour  with  reference  to  Naegele's 
Obliquity,"  Trans.  Obstet.  Soc,  London,  Vol.  XXV.,  1883,  p.  2.58. 


Anomalies  of  the  Pelvis.  729 

of  posterior  obliquity  is  sufficient  to  determine  the  direction  of  the 
tilting,  which  the  resistances  then  increase.  The  effect  is  produced 
in  the  following  way.  The  component  of  the  oblique  force  acting 
perpendicularly  to  the  axis  of  the  brim  pushes  the  condyles  for  wards  ; 
this  calls  out  a  reaction  of  the  anterior  pelvic  wall  directed  backwards, 
but  passing  through  the  centre  of  the  head  or  nearly  so.  Thus  is 
produced  a  "  coujjle  "  or  pair  of  equal  and  oj^posite  forces,  not  in 
the  same  straight  line,  tending  to  tilt  the  sagittal  suture  backward, 
and  produce  Naegele-obliquity. 

Another  reason  is  probably  the  effect  of  friction  against  the 
sacral  promontory.  It  might  at  first  sight  be  supposed  that  friction 
would  be  greater  at  the  anterior  part  of  the  pelvis,  where  the  surface 
of  contact  is  greater.  A  mathematical  consideration  of  the  ques- 
tion, however,  shows  that  exactly  the  contrary  is  the  case.-^  This 
result  depends  upon  the  fact  that  the  curvature  in  the  plane  of  the 
brim  of  the  head  where  it  is  in  contact  with  the  anterior  j)elvic  wall 
is  less  than  that  of  a  circle  having  as  its  diameter  the  conjugate 
diameter  of  the  pelvis.  Hence  the  posterior  side  of  the  head  is 
retarded  most  by  friction  against  a  projecting  promontory.  It  is 
retarded  still  more  if  the  promontory  makes  a  depression  in  the 
head  by  its  pressure.  A  kind  of  ledge  is  then  formed,  which  offers 
a  greater  resistance  than  that  of  friction  proper.^ 

There  are  exceptional  cases,  amounting,  according  to  Litzmann, 
to  about  one-fourth  of  the  whole,  in  which  the  oj)posite  of  Naegele- 
obliquity  occurs,  and  the  sagittal  suture  is  displaced  forward 
(posterior  parietal  presentation)  (Fig.  177,  p.  267).  An  anterior 
obliquity  of  the  uterus,  as  from  pendulous  abdomen,  tends  to 
produce  this  result  when  the  resistances  come  into  play. 

In  general,  the  maximum  degree  of  Naegele-obliquity  is  observed, 
as  according  to  the  above  explanation  it  ought  to  be,  when  the 
head  is  arrested  above  the  brim.  In  such  a  case  I  have  found  the 
sagittal  suture  within  an  inch  of  the  promontory.  If  considerable 
before,  it  becomes  diminished  as  the  head  enters  the  brim,  being 

1  It  must  be  remembered  that  friction  is  not  increa.sed  by  increasing  the  surface  of 
contact.  If  the  surfaces  are  plane,  the  total  friction  remains  the  same,  the  friction 
being  proportional  to  the  pressure  over  each  small  element  of  area. 

2  By  Goodell  it  is  stated  that  the  sagittal  suture  is  slightly  displaced  forwards  at  the 
earlier  part  of  its  passage,  before  its  main  displacement  backwards  begins.  Matthews 
Duncan  held  the  same  view.  This  would  imply  that  the  anterior  side  of  the  head  is 
at  first  most  retarded,  as  was  found  to  be  the  case  in  the  experiments  of  Matthews 
Duncan  with  an  after-coming  head.  No  satisfactory  mechanical  explanation  has 
hitherto  been  suggested  for  this.  It  is  possiVjle  that,  contact  being  wider  in  front,  a 
more  extensive  fold  of  skin  may  be  pushed  up  there  than  by  the  sacral  promontory, 
and  that  this  may  cause  the  greater  retardation,  before  the  head  is  tightly  enough 
engaged  for  friction  pioper  to  liave  much  effect.  No  other  authors,  however,  describe 
this  primary  displacement  of  the  sagittal  suture  forwards,  and  I  have  generally  found 
it  displaced  Ijack wards  when  first  observed. 


730  The  Practice  of   Midwifery. 

reduced  more  nearly  to  that  degree  which  is  mechanically  advan- 
tageous. The  extra  resistance,  from  friction,  or  from  friction  and 
depression,  caused  by  the  sacral  j)romontory,  tends,  however,  to 
maintain  or  to  increase  the  obliquity  beyond  the  advantageous 
point.  The  obliquity  may  be  reduced  also,  during  a  slow  passage, 
through  shortening  of  the  biparietal  diameter  from  moulding. 
But  some  degree  of  obliquity  is  generally  maintained  till  the 
superior  strait  is  passed.  Then  when  the  liead  meets  the  inclined 
plane  of  the  pelvic  floor,  its  advanced  part  is  pushed  forward  under 
the  pubic  arch,  and  the  opposite  obliquity  is  so  produced  as  in 
normal  labour.  Thus  the  lateral  flexion  of  the  head  toward  the 
IDosterior  shoulder  is  at  this  stage  converted  into  lateral  flexion 
toward  the  anterior  shoulder  (see  p.  263). 

When  it  is  said  that  lateral  or  biparietal  obliquity  is  produced  by 
a  rotation  of  the  head  upon  its  antero-posterior  axis,  it  is  not  meant 
that  the  rotation  takes  place  without  a  concomitant  advance  of  the 
head,  or  that  one  side  of  the  head  actually  recedes.  In  general, 
one  side  is  merely  retarded  more  than  the  other.  But  in  some 
cases  the  rotation  may  imply  an  actual  recession  of  one  side  of  the 
head,  as  when  lateral  obliquity  is  produced  when  the  head  is 
completely  arrested  above  the  brim. 

In  some  cases,  again,  when  the  resistance  at  the  promontory  is 
unusually  great,  in  consequence  of  a  depression  being  produced  in 
the  head,  the  posterior  side  of  the  head  may  be  actually  arrested, 
while  the  anterior  is  advancing.  The  movement  may  then  be 
regarded  as  a  rolling  upon  the  sacral  promontory.  When  the 
depression  in  the  head  is  found  to  be  round,  it  is  a  sign  that  such 
an  arrest  of  the  posterior  side  has  taken  place.  In  the  commoner 
case,  in  which  it  forms  a  groove,  there  has  been  merely  retardation. 
A  spoon-shaped  depression  indicates  an  intermediate  condition, 
probably  complete  arrest  of  the  posterior  side  during  a  part  only 
of  the  passage. 

It  is  sometimes  stated  that  in  the  earlier  part  of  the  passage  the 
head  rotates  or  revolves  upon  a  transverse  axis  passing  through 
the  sacrum,  in  the  lower  part  upon  one  passing  through  the 
symphysis  pubis.  This,  however,  is  only  a  graphic  and  popular 
mode  of  representing  the  most  striking  part  of  the  motion  of  the 
head,  and  is  not  strictly  accurate,  since  it  disregards  other  parts  of 
the  motion,  namely,  all  rotations  except  that  in  the  antero-posterior 
plane  of  the  pelvis.^ 

1  By  Matthews  Duncan  a  distinction  was  made  between  rotations  of  the  head  or 
body  of  the  foetus  on  its  own  centre,  and  what  he  called  "  revolutions,"  that  is  to  say, 
rotations  on  an  external  axis  ("  On  the  Revolutions  of  the  Foetal  Head,"  Trans.  Obstet. 
Soc,  London,  Vol.  XX.,  1878,  p.  151).      The  word    "revolution,"  however,  is  more 


Anomalies  of    the  Pelvis.  731 

Path  of  the  Centre  of  the  Head. — In  the  flattened  pelvis,  in  conse- 
quence of  the  displacement  forward  of  the  sacral  promontory,  the 
centre  of  the  pelvic  brim  is  displaced  forward  to  half  the  same 
degree,  also  the  pelvic  inclination  is  sometimes  increased,  although 
in  the  rachitic  flattened  pelvis  it  is  generally  diminished  (see  p.  723). 
From  both  these  causes  the  axis  of  the  pelvic  brim  may  be  inclined 
more  forward  than  usual,  and  the  axis  of  the  uterus  has  then 
usually  a  posterior  obliquity  in  reference  to  the  axis  of  the  brim, 
even  when  the  fundus  is  thrown  forward  in  a  pain.  The  head 
being  then  kept  back  by  the  anterior  uterine  wall,  its  centre  will 
lie  at  first  behind  the  axis  of  the  brim  (a  o.  Fig.  22,  p.  21).  When 
this  is  the  case  its  centre  will  have  to  describe  a  curve  having  its 
concavity  backward  at  its  entrance  into  the  brim,  before  proceeding 
along  the  nearly  straight  portion  of  the  pelvic  axis  (a  b,  Fig.  22, 
p.  21).  This  curve  has  been  described  by  E.  Barnes  under  the 
title  of  the  "  curve  of  the  false  promontory,"  and  more  recently 
under  the  title  of  "  Barnes'  curve,"  as  being  followed  by  the  head 
in  normal  labour  as  well  as  in  the  flattened  pelvis.  It  is  drawn  by 
Barnes  as  a  semicircle,  having  its  centre  at  the  sacral  promontory, 
and  the  so-called  curve  of  Carus  as  another  semicircle  having  its 
centre  in  the  symphysis  pubis.  But  it  has  already  been  shown 
that  the  normal  path  of  the  head  does  not  approximate  to  an  arc  of 
a  circle  except  in  the  lower  part  of  its  course  through  the  soft  parts 

appropriately  applied  to  the  path  of  the  centre  of  a  body,  independent  of  any  rotations 
that  may  take  place  around  that  centre,  as,  for  example,  in  speaking  of  the  revolutions 
of  a  planet  about  the  sun.  In  mechanics  the  word  "  rotation,"  and  not  "  revolution," 
is  used,  if  it  is  intended  to  represent  the  whole  motion  of  a  body,  whether  the  axis 
of  rotation  is  internal  or  external.  If  the  motion  is  all  iu  one  plane,  it  is  only  two 
different  ways  of  describing  the  same  thing  to  say  that  a  body  is  rotating  round  an 
external  centre  of  instantaneous  rotation,  or  to  say  that  it  is  rotating  in  such  or  such  a 
way  round  its  centre,  while  its  centre  is  moving  in  such  or  such  a  path. 

But  this  is  not  the  case  when  the  motion  is  in  three  dimensions,  like  that  of  the 
fcetus.  The  only  accurate  mode  is  then  to  describe  the  path  of  the  centre  of  the  body 
(or  any  other  convenient  point  within  it),  and  the  rotation  or  rotations  about  that 
centre.  The  component  rotations  in  three  rectangular  directions  may  be  combined 
into  a  single  resultant  rotation  ;  but  this  cannot  be  combined  with  the  movement  of 
translation  into  a  single  rotation  about  an  external  axis,  unless  the  two  happen  to  lie 
in  the  same  plane.  In  the  case  of  a  body  like  the  foetus,  moving  in  all  directions 
under  the  axis  of  various  forces,  the  chances  are  infinity  to  one  against  this  being  so, 
except  in  the  case  in  which  the  body  is  rolling.  As  already  mentioned,  the  motion  of 
the  foetal  head  may  sometimes  be  a  rolling  motion.  There  is  then  an  axis  of  instan- 
taneous rotation  passing  through  a  point  on  its  surface,  and  constantly  changing  its 
position.  Otherwise  no  axis  of  instantaneous  rotation  exists,  and  the  probability  is  also 
very  great  against  its  being  even  an  approximate  representation  of  the  whole  motion 
to  call  it  a  rotation  or  "revolution"  about  an  external  axis.  The  principle  hei'e 
described  is  one  simply  of  solid  geometry,  although  it  is  used  as  a  basis  in  the  dynamics 
of  rigid  bodies.  (See  Routh,  Treatise  on  Rigid  Dynamics,  Chapter  V.)  The  conclusion 
here  stated  may  thus  be  summarised  : — (1.)  No  axis  of  instantaneous  rotation  (the 
"revolution"  of  Matthews  Duncan)  exists  for  a  moving  body,  unless  the  movement 
is  limited  to  one  plane.  (2.)  The  movement  of  the  foetal  head  is  not  limited  to  one 
plane,  unless  in  the  exceptional  case  when  the  movement  is  a  rolling  one  ;  and  in  this 
latter  case  the  axis  of  instantaneous  rotation  is  not  external,  but  passes  through  a 
point,  on  the  surface  of  the  head. 


732  The  Practice  of   Midwifery. 

(see  pp.  21,  22).  So  the  "  curve  of  the  false  promontory  "  is  only- 
followed  for  a  short  space,  and  ceases  when  the  centre  of  the  head 
reaches  the  plane  of  the  brim  at  a^  (Fig.  22).  From  that  point  the 
path  is  for  some  distance  nearly  a  straight  line,  as  in  the  normal 
pelvis.  In  a  normal  pelvis  it  does  not  appear  that  the  centre  of 
the  head  lies  initially  behind  the  axis  of  the  brim  (a  o,  Fig.  22). 
Even  in  the  flattened  pelvis  it  does  not  necessarily  do  so.  It  does 
not,  when  the  pelvic  inclination  is  notably  lessened,  as  it  generally 
is  in  rickets,^  nor  when  the  uterus  is  anteverted  from  want  of  room 
in  the  abdomen.  In  such  cases  no  "  curve  of  the  false  promontory  " 
is  followed  at  all,  but  the  path  of  the  head  may  be,  at  first,  nearly 
the  axis  of  the  brim,  or  even  a  curve  having  its  concavity  forward, 
especially  when,  at  the  commencement  of  labour,  the  head  lies  far 
forward,  overhanging  the  pubes,  being  pushed  forward  by  a 
prominent  lumbar  curve. 

Mechanism  of  Labour  with  the  after-coming  Head. — The  long 
diameter  of  the  after-coming  head  enters  the  longest  diameter  of 
the  pelvis  in  the  same  way  as  that  of  the  fore-coming  head.  In 
this  case,  also,  the  head  may  pass  either  in  flexion  or  in  extension, 
according  as  the  biparietal  diameter,  or  that  engaged  in  the  con- 
jugate, is  most  resisted.  But  the  tendency  to  extension  is  generally 
increased  by  the  traction  which  has  to  be  made  in  order  to  bring 
the  head  through  the  brim.  On  account  of  the  posterior  position 
of  the  condyles,  the  traction  force  tends  to  bring  down  the 
occiput  most.  The  occipito-mental  diameter  may  thus  be  thrown 
across  the  transverse  diameter  of  the  pelvis,  and  be  unable  to 
pass,  especially  if  the  pelvis  is  generally  contracted  as  well  as 
flattened. 

1  It  is  held  by  R.  Barnes  that,  even  in  normal  labour,  the  centre  of  the  head  is  con- 
strained to  follow  "  Barnes'  curve "  still  further,  and  is  guided  backvpard  into  the 
hollow  of  the  sacrum,  by  what  he  calls  the  anterior  or  uterine  valve,  that  is  to  say,  by 
the  anterior  lip  of  the  os,  extending  lower  over  the  head,  in  reference  to  the  plane  of 
the  brim,  than  the  posterior.  This  implies  a  displacement  backwards  of  the  os  uteri  in 
reference  to  the  axis  both  of  the  brim  and  of  the  uterus,  and  there  is  no  evidence  that 
this  exists  normally.  The  anterior  lip  of  the  os  is  indeed  often  more  noticeable  than 
the  posterior  as  overlapping  the  head,  but  generally  only  because  the  examining  finger 
first  impinges  upon  it,  the  direction  of  the  vagina  being  nearly  at  right  angles  to  the 
axis  of  the  brim.  In  Braune's  frozen  section  (Fig.  131,  p.  220)  the  anterior  lip  of  the 
external  os  is  notably  higher  than  the  posterior  in  reference  to  the  plane  of  the  brim, 
and  not  lower,  as  represented  in  R.  Barnes'  diagrams.  This  is  explained,  as  a  normal 
condition,  by  the  drawing  up  in  labour  of  the  anterior  pelvic  triangle  (see  p.  223),  It 
appears  that  it  is  only  when  full  dilatation  of  the  os  is  delayed  some  time  after  the 
rupture  of  the  membranes,  and  after  the  descent  of  the  head  near  to  the  pelvic 
floor,  that  the  anterior  lip  of  the  os  may  be  sometimes  pushed  lower  than  the  posterior, 
in  reference  to  the  plane  of  the  brim,  by  the  occiput,  which  is  descending  in  advance 
of  the  forehead,  in  consequence  of  the  flexion  of  the  head. 

2  In  R.  Barnes'  figure  showing  the  curve  of  the  false  promontory  (Lectures  on 
Obstetric  Operations,  p.  71:),  the  inclination  of  the  brim  is  represented  as  increased  in 
rickets,  although  in  the  sectional  views  of  the  several  pelves  ((.)}}.  cit,,  p.  286),  it  is 
correctly  drawn  as  diminished. 


Anomalies  of  the  Pelvis. 


733 


Lateral  obliquity  will  also  occur  in  the  passage  of  the  after- 
coming  head.  Usually  the  posterior  side  is  most  retarded  by 
the  promontory  of  the  sacrum  for  the  same  reason  as  before, 
especially  when  the  expulsion  is  effected  by  the  natural  powers.  In 
experiments  made  with  an  after-coming  head  and  a  wooden  pelvic 
brim,  with  various  degrees  of  flattening,  Matthews  Duncan  ^  found 


Fig.  364. — The  rhomboid  of  Michaelis  in  a,  woman  with  a  well-formed  pelvis. 

that  there  was  first  a  deviation  of  the  base  of  the  skull  forwards, 
and  afterwards  backwards,  the  direction  of  traction  being  perpen- 
dicular to  the  brim.  This  implies,  first,  a  retardation  of  the  anterior 
side,  then  a  more  important  retardation  of  the  posterior.^ 


Diagnosis. — With  a  rachitic  pelvis  there  will  usually  be  some 
signs  of  the  disease  in  the  body  generally.      The  stature  will  be 

'  'J'raiJH.  Obfitet.  Hoc,  London,  Vol.  XX..,  1878,  p.  1.51. 

'-^  For  a  possible  mechanical  explanation  of  the  former,  see  note,  p.  729. 


734  The  Practice  of   Midwifery. 

short,  especially  the  limbs ;  the  tibise  perhaps  bowed  or  thickened, 
and  there  may  be  a  rickety  rosary  present  on  the  ribs.  In  well- 
marked  cases  the  rhomboid  of  Michaelis  (Fig,  364)  becomes  more 
triangular  in  form.  As  regards  the  pelvis,  the  most  valuable 
sign  of  rickets  is  the  change  of  relation  between  the  Dist.  Sp.  II. 
and  Dist.  Cr.  II.  already  described  (p.  721),  There  is  usually  a 
depression  in  the  sacral  region  between  the  ilia,  in  consequence 
of  the  sinking  of  the  sacrum,  and  the  anus  looks  more  backward 
than  usual.  General  contraction  will  be  revealed  by  general 
dimiiiution  of  the  external  diameters,  as  well  as  by  want  of  space 
detected  on  internal  examination.  The  convexity  of  the  anterior 
surface  of  the  sacrum,  and  when  present  the  marked  bending 
forward  of  its  lower  extremity,  can  be  recognised.  The  most 
important  sign,  as  regards  the  probable  difficulties  of  delivery,  is 
the  estimate  of  the  diagonal  conjugate  diameter  (see  p.  705),  and 
the  calculation  from  this  of  the  true  conjugate.  This  is  especially 
the  case  when  the  pelvis  is  flattened  only,  with  little  or  no  general 
contraction,  whether  rickets  has  anything  to  do  with  the  causation 
of  the  deformity  or  not. 

When  labour  has  commenced  the  existence  of  disproportion  of 
some  sort  is  indicated  by  the  head  remaining  high  above  the  pelvis, 
or  by  its  not  descending  upon  the  os  uteri  to  continue  the  dilata- 
tion, when  dilatation  has  progressed  satisfactorily  up  to  the  time 
of  the  rupture  of  the  membranes.  If  in  addition  the  sagittal  suture 
is  found  to  remain  in  a  nearly  transverse  position,  or  with  the 
occij)ut  directed  a  little  backwards,  a  flattened  pelvis  may  be  sus- 
pected. A  marked  degree  of  Naegele-obliquity  or  displacement  of 
the  sagittal  suture  backwards  towards  the  promontory,  also  usually 
indicates  a  flattened  pelvis.  The  projecting  promontory  of  the 
sacrum,  if  one  exists,  may  then  usually  be  felt. 

Eaee  Forms  op  Flattened  Pelvis. 

The  Pelvis  of  Double  Congenital  Dislocation   of  the  Hips, 

— Although  this  anomaly  has  been  generally  called  a  dislocation, 
it  is  in  most  cases  a  fault  of  development,  no  acetabulum  being 
formed  in  the  proper  situation,  but  the  head  of  the  femur  resting 
upon  the  dorsum  of  the  ilium,  behind  and  above  its  natural  situa- 
tion. Some  have  supposed  that  the  condition  may  result  from 
rupture  of  the  ligamentum  teres,  through  traction  upon  the  leg  in 
pelvic  presentations. 

Resulting  Changes  in  the  Pelvis. — It  might  be  suj)posed,  at  first 
sight,  that,  the  points  of  application  of  the  reactions  to  the  body- 


Anomalies  of  the  Pelvis. 


735 


weight  through  the  heads  of  the  femora  being  displaced  backward, 
the  pelvic  inclination  would  be  diminished,  to  maintain  the  balance 
of  the  body.  In  point  of  fact,  however,  it  is  found  that  the  pelvic 
inclination  is  increased,  and  that  the  balance  is  maintained  by  an 
increased  lordosis  of  the  lumbar  vertebrae,  by  which  the  trunk  and 
shoulders  are  thrown  back.  The  resulting  figure  is  shown  in 
Fig.  365.  The  reason  of  the  increase  of  the  pelvic  inclination  is, 
that  a  pressure  backwards  on  the  anterior  half  of  the  pelvic  ring 
is  exercised  by  the  ilio-femoral  ligaments, 
and  the  iliaco-psoas  muscles,  in  consequence 
of  the  displacement  backward  of  their  attach- 
ment to  the  femora.  Assuming  that  it  is  not 
compensated  for  by  a  diminution  of  pelvic 
inclination  to  preserve  the  balance,  the  dis- 
placement backwards  of  the  heads  of  the 
femora  itself  tends  to  increase  the  pelvic 
inclination.  For  the  posterior  half  of  the 
pelvic  ring  is  in  consequence  pushed  up 
more  by  the  pressure  of  the  femora,  and  the 
anterior  half  less,  than  usual.  In  conse- 
quence of  the  weight  being  transmitted  more 
than  usual  through  the  posterior  half  of  the 
pelvis,  the  anterior  half  is  found  to  be  lighter 
and  more  slender  than  in  the  normal  pelvis. 
In  consequence  of  the  increase  of  the 
pelvic  inclination,  a  greater  proportion  of  the 
body-weight  acts  in  the  plane  of  the  brim, 
the  leverage  exerted  on  the  innominate  bones 
is  increased,  and  the  inward  thrust  of  the 
heads  of  the  femora  acts  not  at  the  aceta- 
bula  but  on  the  dorsa  of  the  ilia.  It  there- 
fore renders  the  iliac  fossae  more  upright,  but 
has  less  tendency  than  usual  to  resist  the 
widening  of  the  pelvis.  The  tendency  to  widening  is  also  increased 
by  the  traction  of  the  ilio-femoral  ligaments  and  the  attachment 
of  the  iliaco-psoas  muscles,  which  are  directed  more  outward  than 
usual.  Hence  arises  a  moderately  flattened  pelvis,  enlarged  trans- 
versely at  the  brim  and  still  more  at  the  outlet,  the  pubic  arch 
being  wide,  and  the  tubera  ischii  far  apart.  It  rarely  causes 
difficulty  in  parturition,  there  being  no  general  contraction 
associated  with  the  moderate  flattening. 

The  Split  Pelvis. — The  split  pelvis,  in  which  there  is  no  bony 
union  between  tlie  pubes,  but  only  a  fibrous  band,   also  generally 


Fig.  365.  —  Pregnancy 
with  double  congenital 
dislocation  of  the  hips. 
(After  Ahlfeld.) 


736  The  Practice  of   Midwifery. 

arises  from  a  fault  of  development.  It  is  usually  associated  with 
ectopia  vesicae  and  imperfect  development  of  the  sexual  organs, 
and  is  therefore  of  little  practical  obstetric  interest.  It  is,  however, 
of  some  importance  in  illustrating  the  action  of  the  mechanical 
forces  concerned  in  pelvic  development. 

Resulting  Changes  in  the  Pelvis. — The  separation  of  the  anterior 
ends  of  the  innominate  bones,  amounting  to  10  cm.  or  over,^ 
necessarily  renders  the  pelvis  relatively  wide.  The  widening  forces, 
namely,  the  reactions  to  the  body-weight  at  the  acetabula,  and  at 
the  tubera  ischii,  therefore  act  at  an  increased  advantage  (see  p.  28), 
and  the  result  is  a  wide  slightly  flattened  pelvis.  The  tension  at 
the  symphysis  pubis  is  not  abolished,  but  is  maintained  by  the 
fibrous  union,  as  is  shown  by  the  fact  that  the  separation  does  not 
go  on  indefinitely  increasing. 

General  Effects. 

Since  the  generally  contracted  and  the  flattened  pelves  are  those 
which  most  frequently  lead  to  practical  difficulty,  certain  general 
efiects  of  these  commoner  forms  of  contraction  will  here  be 
considered. 

Effects    of    Pelvic    Contraction    upon   Pregnancy. — In    the 

earlier  months,  if  there  is  a  projecting  sacral  promontory,  and  if 
the  uterus  is  retroflexed  or  retroverted,  the  pelvic  contraction  may 
favour  incarceration,  the  promontory  preventing  the  fundus  uteri 
from  readily  rising  out  of  the  pelvis  into  the  abdomen  as  it 
enlarges.  In  the  later  months,  the  uterus,  with  the  foetus,  is 
generally  situated  higher  than  usual  in  the  abdomen,  if  the  head 
is  too  large  to  lie  low  within  the  pelvis.  Hence  deviations  of  the 
uterus,  especially  anteversion,  with  pendulous  abdomen  or  lateral 
obliquity,  are  commoner  than  usual,  especially  when  the  stature  is 
short,  as  in  rachitic  patients,  and  the  abdomen  does  not  afl'ord  room 
enough  for  the  uterus  in  its  usual  position.  If  the  patient  is  tall 
there  may  be  unusual  prominence  of  the  fundus  uteri.  Such 
deviations  become  progressively  more  marked  in  repeated  preg- 
nancies, from  tbe  increasing  laxity  of  the  abdominal  walls. 
Malpresentations  are  at  least  five  times  as  common  as  with  a 
normal  pelvis.  Thus  vertex  presentations  occur  in  about  84  per 
cent,  of  cases  of  contracted  pelves  as  contrasted  with  96  to  97  per  cent, 
in  normal  pelves.  This  result  depends  partly  upon  the  frequent 
obliquity  of  the  uterus,  partly  upon  the  high  position  of  the  head, 

1  Breus  and  Kolisko,  loo.  ciL,  Bd.  1,  Th.  1,  p.  107. 


Anomalies  of  the  Pelvis.  737 

the  consequent  readiness  with  which  it  deviates  to  one  side,  and 
the  ease  with  which  the  irregular  pelvis  allows  the  descent  of  a  hand, 
arm,  funis,  or  other  part. 

Effects  of  Pelvic  Contraction  upon  Labour. — In  the  early 
stage  of  labour  the  head  is  generally  high  above  the  brim.  The 
bag  of  membranes  may  then  protrude  more  deeply,  in  a  sausage- 
like form,  through  the  os,  and,  owing  to  the  head  not  engaging  and 
its  ball-valve-like  action  being  absent,  the  forewaters  are  exposed  to 
the  full  force  of  the  general  intrauterine  pressure.  As  a  result  the 
membranes  often  rupture  prematurely,  and  their  rupture  is 
accompanied  not  infrequently  by  the  descent  of  the  cord  or  of  some 
of  the  limbs  of  the  foetus.  After  the  rupture  of  the  membranes, 
dilatation  of  the  cervix,  if  incomplete,  ceases,  if  the  presenting  part 
is  unable  to  descend  and  continue  it.  The  cervix  may  even  contract 
again  to  some  extent.  Nearly  the  whole  of  the  liquor  amnii 
quickly  drains  away  if  the  presenting  part  is  unable  closely  to  fill 
the  lower  segment  of  the  uterus.  For  a  very  short  time  after 
rupture  of  the  membranes,  if  the  head  cannot  enter  the  brim,  the 
pains  may  be  less  vigorous  than  usual,  from  a  lack  of  reflex 
stimulus  through  pressure  on  the  cervix.  But  before  long  the 
uterine  wall  being  more  stimulated  than  usual  by  the  pressure  of 
the  foetus,  the  pains  assume  an  expulsive  character,  even  if  the 
rupture  of  the  membranes  has  taken  place  before  the  dilatation  of 
the  OS  has  proceeded  far. 

The  further  course  of  labour  depends  greatly  upon  the  relation 
between  the  size  of  the  head  and  that  of  the  pelvis,  upon  the 
strength  of  the  uterine  muscles,  and  the  character  of  the  pains.  If 
these  are  vigorous  they  are.  stimulated,  up  to  a  certain  point,  by  the 
resistance  encountered,  and  labour  may  take  place  easily  and 
relatively  rapidly  in  moderate  degrees  of  contraction.  On  the  other 
hand,  and  especially  in  multipara  with  a  pendulous  abdomen, 
exhaustion  of  the  uterine  muscle  may  set  in  quickly,  and,  as  the 
patient  is  unable  to  render  any  assistance  with  her  abdominal 
muscles,  the  labour  may  be  delayed  or  even  arrested.  The 
retraction  of  the  thick  muscular  portion  of  the  uterus  (see  p.  622), 
and  thinning  of  the  distensible  portion,  especially  the  cervix,  then 
take  place  rapidly,  and  there  is  danger  of  rupture,  if  the  obstacle 
is  insuperable.  If  this  does  not  occur,  and  the  patient  is  left 
untreated,  eventually  exhaustion  supervenes.  The  pains  may  die 
away  for  a  time,  and  again  return,  or  the  uterus  may  at  once  pass 
into  the  state  of  continuous  action  or  tetanic  contraction  (see  p.  622), 
and  the  constitutional  signs  of  protracted  labour,  which  have  been 

M.  47 


738  The  Practice  of   Midwifery. 

already  enumerated  (see  pp.  619 — 623),  appear.  If  the  uterine 
wall  is  initially  thin,  or  the  pains  weak,  the  stage  of  exhaustion 
comes  on  much  earlier. 

Effect  of  Pressure  on  the  Soft  Parts. — The  long  continuance 
of  labour  and  the  pressure  of  the  child's  head  lead  to  congestion 
of  the  mucous  membrane  of  the  cervix  and  vagina,  with  extravasa- 
tion of  blood  and  destruction  of  the  epithelium,  which  favours  the 
occurrence  of  infection.  At  the  same  time  the  liquor  amnii,  after 
rupture  of  the  membranes,  is  very  likely  to  undergo  decomposition, 
and  the  normal  vaginal  discharge  is  replaced  by  a  thin,  blood- 
stained secretion,  which  forms  a  very  favourable  nidus  for  the 
growth  of  infective  organisms. 

Severe  injuries  to  the  soft  parts  are  almost  invariably  caused  by 
the  head,  not  by  other  parts  of  the  foetus.  They  are  produced 
rather  by  prolonged  pressure  than  by  rapid  transit,  and  therefore 
occur  chiefly  in  head  presentations. 

In  cases  of  generally  contracted  pelves,  where  the  head  when 
engaged  in  the  pelvis  exercises  uniform  pressure  on  the  part  of  the 
uterus  lying  between  it  and  the  pelvic  brim,  marked  oedema  and 
congestion  of  the  cervix  occur.  In  cases  of  obstructed  labour, 
accompanied  with  extreme  impaction,  the  swelling  of  the  caput 
succedaneum  and  the  oedema  of  the  soft  parts  may  be  so  marked 
that  there  may  be  great  difficulty  in  distinguishing  between  them. 

In  the  flat  pelvis  the  uterine  wall,  generally  the  supra-vaginal 
portion  of  the  cervix,  may  be  bruised  and  injured  by  pressure 
against  the  promontory  of  the  sacrum,  against  the  pelvic  wall 
generall}^,  or  against  any  other  projections  which  may  exist. 
Hence  may  follow  haemorrhages  in  its  substance,  and  subsequent 
inflammation.  Sometimes  the  injury  produced  may  be  the  starting 
point  of  rupture  in  labour.  More  frequently,  a  necrotic  j)rocess 
takes  place  afterwards,  especially  over  the  site  of  the  sacral  pro- 
montory. The  injury  is  more  extensive  on  the  surface  of  the 
utero-vaginal  canal  where  the  tissue  is  exposed  to  the  access  of  air 
and  germs,  and  rarely  causes  perforation  through  the  peritoneum. 

Injuries  to  the  anterior  wall  of  the  genital  canal,  from  pressure 
against  the  pubes,  affect  the  vagina  much  more  often  than  the 
cervix.  Tlius  vesico-vaginal  fistula  is  much  more  common  than 
utero-vesical  fistula.  Hence  it  is  rare  that  sloughing  in  this 
situation  results  from  pelvic  contraction  so  great  as  to  arrest  the 
head  above  the  brim.  It  more  commonly  arises  when  the  head 
has  partly  entered  the  vagina,  and  is  long  detained  in  that  position, 
either   from  moderate  disproportion  or  uterine  inertia,  while  no 


Anomalies  of  the  Pelvis.  739 

artificial  assistance  is  given.  Here  also  the  lesion  is  most  extensive 
on  the  vaginal  surface.  It  very  rarely  arises  from  immediate 
laceration  in  delivery,  instrumental  or  otherwise,  almost  always 
from  a  gradual  process  of  sloughing  afterwards.  The  fistula 
then  becomes  manifest,  by  the  escape  of  urine,  only  after  the 
lapse  of  some  days.  Sloughing  may  also  occur  after  prolonged 
pressure  in  other  parts  of  the  vagina.  This  may  lead  to  general 
cicatricial  contraction  in  the  end.  If  the  slough  is  posterior,  a 
recto-vaginal  fistula  may  be  formed,  but  this  is  much  more  rare 
than  a  vesico-vaginal  fistula.  Injuries  to  the  perineum  and 
vaginal  outlet,  which  may  be  promoted  by  contraction  of  the  bony 
outlet,  especially  of  the  pubic  arch,  will  be  considered  hereafter 
(see  Chapter  XXXVII).. 

Effects  of  Pressure  on  the  Child's  Head.  —  The  caput 
succedaneum  or  scalp  tumour  arises  from  a  limited  portion  of 
the  head  being  unsupported,  while  the  rest  is  subject  to  pressure. 
It  may  be  produced  while  the  head  is  at  or  above  the  brim  in 
contracted  pelves,  but,  in  consequence  of  the  mechanism  of  its 
production,  it  is  not  so  readily  produced  when  the  obstacle  lies 
in  one  diameter  only  of  a  flattened  pelvis,  as  when  there  is 
uniform  contraction,  or  when  the  obstacle  is  due  to  rigidity  of 
soft  parts.  The  presence  of  a  considerable  caput  succedaneum 
indicates  not  only  the  existence  of  resistance,  but  that  the  pains 
are  effective,  and  is  therefore  not  altogether  unfavourable  when 
pelvic  contraction  is  known  to  exist. 

In  cases  of  difficult  labour  in  contracted  pelves  marked  moulding 
of  the  head  usually  occurs,  and  there  may  be  grooved  or  spoon- 
shaped  depressions  on  the  parietal  bones,  the  result  of  the  pressure 
of  the  sacral  promontory.  These  will  be  described  more  in  the 
chapter  on  injuries  to  the  child  (see  Chapter  XLII.). 

Prognosis  in  Contracted  Pelves. — Pelvic  contraction  in  the 
more  extreme  degrees  is  fatal  to  the  child,  unless  delivered  by 
Csesarean  section,  and  very  dangerous  to  the  mother.  Even  in 
less  extreme  degrees  of  contraction  the  risk  to  the  mother  is 
greatly  increased  from  the  exhaustion  consequent  upon  prolonged 
labour,  from  the  access  of  air  to  the  uterus  consequent  upon  the 
total  escape  of  the  liquor  amnii  or  the  performance  of  operations, 
and  from  the  injury  to  the  soft  parts  from  pressure  between  the  head 
and  the  pelvis,  or  caused  by  the  operations  necessary  to  effect 
delivery.  The  bruised  and  injured  soft  parts  become  inflamed,  and 
the  inflammation  is  liable  to  assume  a  septic  form,  and  extend  to 

47—2 


740  The  Practice  of   Midwifery. 

the  peritoneum  or  affect  the  general  system.  The  risk  is  greater 
the  nearer  the  injured  parts  are  to  the  peritoneum.  The  risk 
increases  to  some  extent  with  the  degree  of  contraction,  although 
the  greatest  difficulties  are  often  met  with  in  cases  of  moderately 
contracted  pelvis,  since  in  these  the  condition  is  so  frequently  not 
recognised  before  the  onset  of  labour.  The  risk  also  increases  with 
the  number  of  children.  This  is  explained  by  the  fact  that  each 
successive  child  is  often  somewhat  larger  than  its  predecessor, 
malpresentations  are  more  common  in  multiparae,  and  the  uterine 
contractions  are  liable  to  be  less  regular  and  less  powerful.  The 
prognosis  to  the  children  is  more  unfavourable.  Many  die  from 
asphyxia  in  consequence  of  the  prolongation  of  labour  and  the 
excessive  pressure. 

Of  5,288  cases  of  contracted  pelvis  among  49,397  births  occurring 
in  the  Clinique  of  Schauta  ^  in  the  years  1892 — 1906,  24  of 
the  mothers  died,  a  mortalitj^  of  '45  per  cent.,  and  491  of  the 
children,  a  mortality  of  9*28  per  cent.  These  figures  demonstrate 
the  dangers  of  labour  in  cases  of  contracted  pelvis  at  the  present 
day  when  the  treatment  is  undertaken  in  a  lying-in  hospital,  and 
may  be  contrasted  with  the  figures  given  by  Spiegelberg,^  who  in 
the  Breslau  Maternity  had  a  maternal  mortality  of  7*9  per  cent. 
(54  in  680),  and  a  foetal  mortality  of  32  per  cent.  (219  in  682). 

Treatment  of  generally  Contracted  and  Flattened  Pelves. — 

Contracted  pelves  may  be  divided  into  four  classes  in  reference  to 
treatment : — (1)  Those  in  which  delivery  of  a  living  child  at  full 
term  by  the  natural  powers,  or  by  the  aid  of  forceps  or  version,  may 
be  expected.  (2)  Those  in  which  delivery  of  a  living  and  viable 
child  by  induction  of  premature  labour  is  probable,  but  not  that  of 
a  living  child  at  full  term.  (3)  Those  in  which  a  living  child 
cannot  pass  through  the  pelvis,  but  a  child  can  be  extracted  after 
embryotomy  without  great  risk  to  the  mother.  (4)  Those  in  which 
dehvery  through  the  natural  passages  is  impossible,  or  involves 
greater  risk  than  the  performance  of  Csesarean  section. 

No  very  positive  line  of  demarcation  can,  however,  be  drawn 
between  these  classes.  Much  depends  upon  the  character  of  the 
pains  and  the  size  of  the  child's  head,  and  these  cannot  be  accurately 
measured  before  delivery.  Moreover,  there  is  a  liability  to  error 
even  in  the  estimate  of  the  conjugate  diameter  by  skilled  observers 
up  to  a  quarter  of  an  inch  or  more,  and  other  diameters  can  still 
less  be  measured  accurately.     Thus  it  happens  that,  on  the  one 

1  Schauta.  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  Vol.  XV.,  No.  5,  p.  311. 

2  Spiegelberg,  Text-book  of  Midwifery,  English  translation,  1888,  Vol.  II.,  p.  82. 


Anomalies  of  the  Pelvis.  741 

hand,  cases  are  recorded  of  a  living  child  at  full  term  passing 
a  conjugate  diameter  of  only  2|  inches,  while  in  other  cases, 
craniotomy  proves  necessary  with  a  conjugate  of  as  much  as  3| 
inches.  Again,  the  inferior  limit  of  space  through  which  delivery 
by  craniotomy  should  be  attempted  is  very  variously  estimated  by 
different  authorities,  and  has  been  much  modified  by  recent 
improvements  in  Ceesarean  section.  Hence  it  is  necessary  not  only 
to  make  careful  measurements  of  the  pelvis,  but  also  to  determine 
as  accurately  as  possible  the  relation  of  the  size  of  the  child's  head 
to  that  of  the  pelvis,  and  to  consider  carefully  the  history  of  former 
deliveries,  in  deciding  the  question  as  to  the  correct  method  of 
treatment  to  be  adopted. 

In  cases  of  flattened  pelvis  having  a  conjugate  of  3 J  inches  or 
more,  it  may  be  expected  that  delivery  will  be  effected  by  the 
natural  powers,  provided  the  pains  are  sti'ong  enough.  These  form 
the  majority  of  the  whole  number.  Unless  the  head  is  unusually 
large,  the  conjugate  diameter  exceeds  the  diameter  of  the  head  likely 
to  engage  in  it,  and  moreover  some  diminution  of  the  corresponding 
diameter  of  the  head  from  moulding  is  to  be  expected.  Hence,  in 
the  early  stage  of  labour,  an  expectant  treatment  should  be  adopted. 
In  this,  as  in  all  cases  of  pelvic  contraction,  much  pains  should 
be  taken  to  avoid  rupture  of  the  membranes  before  full  dilatation 
of  the  OS.  The  patient  should  be  kept  lying  down,  and  restrained 
from  making  premature  bearing- down  efforts. 

Of  the  5,288  cases  recorded  by  Schauta,  in  4,116  spontaneous 
labour  occurred,  with  4  maternal  deaths,  or  a  mortality  of  '09  per 
cent.,  and  91  foetal  deaths,  or  a  mortality  of  2'2  per  cent.,  results 
better  than  those  obtained  by  any  other  method  of  treatment  with 
the  exception  of  Csesarean  section,  which  gave  a  slightly  lower 
foetal  mortality,  namely,  1*7  per  cent. 

After  rupture  of  the  membranes,  care  should  be  taken  to  correct 
any  anteversion  or  other  deviation  of  the  uterus  from  the  axis  of 
the  brim.  If  pains  are  feeble,  it  is  often  useful  to  keep  the  patient 
on  her  back,  so  that  gravity  may  assist  the  advance  of  the  foetus 
and  reflex  stimulus  be  increased.  Moderate  external  pressure  may 
also  be  used  during  the  pains.  A  ceitain  influence  can  be  exercised 
on  the  flexion  or  the  extension  of  the  head  by  the  position  of  the 
patient.  Obliquity  of  the  uterus  tends  to  cause  advance  of  that 
part  of  tbe  head  opposite  to  the  direction  of  the  obliquity.  Hence, 
if  the  occiput  is  directed  as  usual  to  the  left,  and  if  it  can  be  made 
out  that  the  diameter  of  the  head  engaged  in  the  conjugate  is  most 
tightly  gripped,  and  that,  therefore,  the  head  has  a  better  chance 
of  passing  by  flexion  than  by  extension  (see  p.  726),  the  usual  left 


742  The  Practice  of   Midwifery. 

lateral  position  is  injurious.  If  the  patient  is  placed  on  her  right 
side,  and  right  obliquity  of  the  uterus  thus  encouraged,  the  descent 
of  the  occiput  will  be  favoured. 

A  reasonable  time  should  be  allowed  to  see  the  effect  of  the 
natural  powers,  especially  if  progress  is  being  made,  but  no  oxytocic, 
as  ergot,  should  be  given.  If  the  pains  begin  to  fail,  or  symptoms 
of  exhaustion,  especially  considerable  acceleration  of  pulse,  appear, 
assistance  should  be  given.  The  greater  is  the  apparent  dispropor- 
tion between  the  foetal  head  and  the  pelvis,  the  less  time  should  be 
allowed  to  elapse  to  exhaust  the  patient's  powers,  because  it  is  then 
more  likely  that  she  will  have  to  undergo  afterwards  the  ordeal  of 
a  difficult  extraction ;  and  the  more  she  is  exhausted  beforehand, 
the  worse  will  her  prospects  be.  The  foetal  heart  should  also  be 
watched.  Any  marked  diminution  of  its  rate,  especially  if  accom- 
panied by  feebleness  of  sound,  shouldbe  an  indication  for  interference 
in  the  interest  of  the  child.  Comparatively  early  interference  is 
especially  indicated  when,  after  rupture  of  the  membranes,  the 
head  cannot  descend  upon  the  os  to  continue  the  dilatation,  though 
even  then  a  reasonable  time  may  be  allowed  to  see  if  the  head  will 
engage  in  the  brim.  If  pains  appear  to  be  so  violent  as  to  threaten 
rupture  of  the  uterus,  especially  if  no  advance  is  being  made, 
interference  should  on  no  account  be  delayed. 

"With  a  flattened  pelvis  having  a  conjugate  between  3f  and  3 
inches,  a  certain  time  may  also  be  allowed  to  nature,  to  see  if  the 
head  will  engage  in  the  pelvis,  but  assistance  should  here  be  given 
earlier,  since  there  is  less  likelihood  of  delivery  being  completed 
by  the  natural  powers  with  a  full-term  child.  If  the  pelvis  is 
generally  contracted,  the  same  rule  will  apply  with  a  conjugate 
up  to  3|  inches;  and  even  with  such  a  conjugate,  craniotomy 
sometimes  becomes  necessary. 

Choice  betiveen  Forceps  and  Version. — Much  controversy  has  taken 
place  on  the  relative  merits  of  the  high  forceps  operation  and 
version  in  the  flattened  pelvis,  and  very  diverse  views  are  still  held 
on  the  subject. 

For  extraction  through  a  flattened  pelvis,  forceps  have  two  great 
advantages : — (1)  A  much  greater  force  can  be  used  than  can  be 
applied  to  the  neck  without  risk  of  injuring  the  spinal  cord.^ 
(2)  The  extraction  may  be  made  gradually,  while  the  extraction  of 
an  after-coming  head  must  be  effected  in  a  minute  or  two  if  the  child 
is  to  be  saved.     Against  these  are  to  be  balanced  the  following 

1  In  the  experiments  on  the  foetus  at  term,  Matthews  Duncan  found  that  the  spinal 
column  gave  way  under  tensions  of  from  90  to  122  lb.,  and  that  decapitation  took 
place  under  tensions  of  from  91  to  141  lb.  (Mechanism  of  Natural  and  Morbid 
Parturition,  p.  136).     A  premature  foetus  might  be  expected  not  to  endure  so  much. 


Anomalies  of  the  Pelvis.  743 

disadvantages  : — (1)  In  the  high  forceps  operation  the  blades  are 
generally  applied  nearly  in  the  transverse  diameter  of  the  pelvis ; 
and,  even  if  any  other  mode  of  application  is  attempted,  the  blades 
naturally  tend  to  fall  into  such  a  position.  The  compression  thus 
exercised  upon  the  head  in  the  transverse  diameter  of  the  pelvis 
tends  to  increase  to  some  extent  the  other  diameters,  but  it  must 
be  remembered  that,  as  Budin  and  Milne  Murray  have  shown,  the 
main  increase  is  in  the  vertical  diameter,  and  therefore  this  objec- 
tion is  not  one  of  much  importance,  (2)  The  same  force  of  com- 
pression tends  to  turn  the  long  diameter  of  the  head  out  of  the 
transverse  into  an  oblique  pelvic  diameter.  (3)  It  is  generally  stated 
as  another  objection  that  the  compression  tends  to  cause  flexion. 
This,  however,  is  not  in  all  cases  a  disadvantage,  if  the  flexion  is 
produced  by  rotation  on  the  diameter  engaged  in  the  conjugate, 
for  this  may  be  the  best  mode  of  passing  the  brim  (see  p.  726). 
It  will  be  a  disadvantage  only  if  the 
bi-parietal  diameter  is  brought  nearer  to  ^^s^"'^^  ^^^ 

the   middle   line,  not  if  the  bi-temporal  //  n^ 

diameter  is  brought  nearer  to  the  side  of      "((- -]W 

the  pelvis  where  the   occiput  lies.     The        u  | 

latter  will  generally  be  the  case,  the  whole         ^  // 

head  sliding  somewhat  in  the  direction  of  \  Jf 

the  occiput,  where  there  is  most  room.  iBkv  J^09^^ 

The  former  effect,  however,  may  be  pro-     ^      ^^^     ,:'^^ 

'  .   ,  Fig.  366.  —  iransverse  section 

duced  to  the  extent  of  the   thiclmess  of        of  foetal  skuU.     a,  a.  Bi- 
one  blade  of  the  forceps,  if  there  is  scanty        parietal,     b,  b.  BUmastoid 

■■-'..  ''  diameter. 

space  in  the  transverse  pelvic  diameter. 

The  comparative  advantages  of  version  are  the  following : — 
(1)  The  head  naturally  adapts  itself  to  the  pelvis  in  that  position  in 
which  it  can  find  most  room.  (2)  The  second  advantage  depends 
upon  the  shape  of  a  vertical  section  of  the  head.  In  Fig.  366 
a  vertical  section  of  the  head  through  the  parietal  tubera  is  shown. 
It  will  be  seen  that  the  section  forms  a  much  more  tapering  wedge 
when  it  enters  the  brim  by  the  base  first  than  when  it  enters  it 
with  the  summit  first.  Now  the  transverse  diameter  of  the  base, 
or  bi-mastoid  diameter,  is  practically  incompressible,  measuring  on 
the  average  about  3  inches.  The  bi-parietal  diameter  exceeds  this 
by  f  inch,  measuring  about  3f  inches  on  an  average.  But  the 
bi-parietal  diameter  can  be  reduced  by  moulding  under  pressure 
to  the  dimensions  of  the  bi-mastoid  without  necessarily  causing  the 
death  of  the  child. 

If,  not  the  bi-parietal  diameter,  but  some  other  transverse 
diameter  of  the  head  engaged  in  the  conjugate  meets  with   the 


744 


The  Practice  of   Midwifery. 


greatest  resistance,  the  same  general  argument  will  apply,  although 
in  this  case  the  original  maximum  transverse  diameter  of  the 
section  will  not  be  quite  so  great  in  proportion  to  the  diameter  of 
the  base. 

Opposed  to  this   advantage  there  is  one   disadvantage   in   the 


Fig.  367. — Transverse  section  of  foetal 
skull.  The  dotted  line  a  a,  b  b,  o  c, 
represents  the  normal  outline.  1,2  2, 
represents  the  alteration  produced 
by  the  compression  described. 


Fig.  368. — Ti-ansvcrse  section  of  foetal 
skull,  a  a,  b  b,  normal  outline. 
1  1,  2,  outline  of  skull  as  com- 
pressed by  extraction  after  ver- 
sion. 


passage  of  the  after-coming  head.  When  it  is  the  diameter  engaged 
in  the  conjugate  which  meets  with  the  greatest  resistance,  traction 
on  the  body  generally  tends  to  produce  extension,  because  the 
condyles  are  generally  posterior  to  this  diameter,  which  is  usually 


Fig.  369. — Passage  of  after-coming  head  through  reniform  flattened  pelvis. 
A.  Promontory  of  sacrum.  B.  Symphysis  pubis,  c.  Space  between  fore- 
head and  ilium.  D.  Depression  in  foetal  head,  e,  f.  Anterior  and  pos- 
terior fontanelles. 


one  only  slightly  behind  the  bi-temporal.  (See  Fig.  369.)  The 
extension  will  go  on  until  it  has  reached  such  a  point  that  the  line 
of  traction  passes  through  the  diameter  gripped  in  the  conjugate. 
Hence  not  merely  the  fronto-occipital,  but  the  occipito-mental,  or 
maximum  vertico-mental  diameter  of  the  head  is  liable  to  be  thrown 
nearly  across  the  transverse  diameter  of  the  pelvis.     It  will  probably 


Anomalies  of  the  Pelvis.  .745 

be  unable  to  pass  in  this  position,  especially  if  there  is  general 
contraction,  as  well  as  flattening  of  the  pelvis.  Hence  the  extended 
position  of  the  after-coming  head  is  often  a  disadvantage  in  com- 
parison with  its  position  in  extraction  by  forceps,  not  an  advantage 
as  is  stated  by  some  authorities. 

It  is  sometimes  stated  that  a  fcetal  head  can  be  brought  through 
a  pelvis  having  a  conjugate  diameter  smaller  by  ^  inch  by 
means  of  version  as  compared  with  forceps.  No  such  general 
statement,  however,  can  be  proved.  Budin,^  by  experiments  on  an 
artificial  pelvis,  with  a  sacral  promontory  movable  to  imitate 
different  degrees  of  contraction,  found  that  a  premature  fcEtus 
could  indeed  be  brought  through  by  version  with  a  less  force  than 
by  forceps  but  that  a  full  term  fcetus  could  not.  Much,  however, 
depends  upon  the  exact  relation  of  the  shape  of  the  pelvis  to  that 
of  the  head.  It  is  undoubted  that,  even  at  full  term,  sometimes  a 
living  foetus,  and  still  more  frequently  a  dead  one,  may  be  extracted 
by  version,  when  forceps  of  an  efficient  pattern  have  been  tried,  and 
have  failed. 

There  is  one  condition  in  which  version  may  have  a  special 
advantage  as  compared  with  extraction  by  forceps.  This  is  when 
it  can  be  made  out  that  there  is  more  room  on  one  side  of  the  pelvis 
than  the  other,  especially  when  this  is  due  to  greater  breadth  of 
the  wing  of  the  sacrum,  and  greater  depth  of  the  depression  at  the 
side  of  the  promontory  on  the  corresponding  side.  Such  a  pelvis 
is  shown  in  Fig.  369,  p.  744.  It  will  then  be  an  advantage  to 
have  the  broad  bi-parietal  diameter  of  the  head  on  the  widest  side 
of  the  pelvis.  Hence  if  the  head  should  present  by  the  vertex  in 
such  a  way  that  the  occiput  is  turned  towards  the  wrong  side,  and 
the  head  is  arrested  at  the  brim,  it  is  desirable  to  perform  version 
so  as  to  bring  the  occiput  to  the  widest  side  of  the  pelvis.  This 
may  always  be  effected,  if  it  is  remembered  that  the  leg  which  is 
brought  down  always  eventually  rotates  anteriorly,  under  the  pubic 
arch.  Hence  the  rule  is  as  follows  : — If  it  is  desired  to  bring  the 
occiput  into  the  right  side  of  the  pelvis,  bring  down  the  right  leg, 
and  conversely. 

Version  is  also  preferable  to  forceps  where  some  other  condition 
is  present  beside  a  contracted  pelvis,  such  as  placenta  prsevia,  and 
in  cases  where  the  head  is  movable  above  the  brim  of  the  pelvis, 
and  either  the  application  of  forceps  or  the  performance  of  version 
is  indicated. 

There  is  one  condition,  on  the  other  hand,  under  which  all 
authorities  are  agreed  that  forceps  should  have  the  preference  over 

^  La  Tele  du  Fcjetus  au  Point  de  Vue  d'Obstetrique,  Paris,  187G. 


746  The  Practice  of   Midwifery. 

version.  This  is  when  the  head  is  ah-eady  engaged  pretty  deeply 
in  the  pelvis,  though  its  maximum  diameters  may  not  j^et  have 
passed  the  brim.  If,  in  addition,  there  is  such  retraction  of  the 
uterus  that  the  internal  os  (or  the  retraction  ring,  see  p.  621) 
can  be  felt  as  a  line  of  transverse  depression  from  the  abdomen  or 
as  an  internal  ridge  above  the  head  on  introducing  the  hand ;  if 
the  uterus  is  so  closely  contracted  round  the  foetus,  that  the  head 
cannot  be  elevated  ;  or  if  the  head  has  passed  out  of  the  cervix 
into  the  vagina,  through  the  drawing  up  of  the  cervix,  it  should 
be  inferred  that  the  case  is  too  far  advanced  for  version,  and 
craniotomy  should  be  at  once  performed,  if  forceps  fail.  For, 
under  these  conditions,  the  attempt  to  perform  version  would  risk 
the  rupture  of  the  uterus,  and  the  interest  of  the  mother  forbids 
such  a  risk  to  be  run  for  the  possible  chance  of  saving  the  child. 
For  the  same  reason,  if  the  mother's  general  state  appears  so 
critical  that  rapid  delivery  is  urgently  called  for,  it  is  generally 
better  not  to  perform  version.  For,  if  craniotomy  proves  necessary 
after  all,  it  is  sometimes  a  more  difficult  and  tedious  operation 
on  the  after-coming  head,  especially  if  the  disproportion  is  very 
great. 

It  is  when  the  head  is  arrested  above  the  brim,  in  a  flattened 
pelvis,  and  the  case  not  too  far  advanced,  that  authorities  differ 
most  as  to  the  course  to  be  pursued.  The  best  plan  appears  to 
be  that  generally  adopted  in  England,  namely,  to  apply  forceps, 
and  try  the  effect  of  moderate  traction,  and  then,  if  this  fails,  to 
perform  version,  unless  the  alternative  of  symphysiotomy  or  pubi- 
otomy  should  be  chosen  by  the  operator,  and  the  patient  and  her 
husband  give  their  consent  to  that  operation.  As  to  the  com- 
parative results  of  forceps  or  version  as  a  first  choice  under  these 
circumstances,  very  much  depends  upon  the  efficiency  of  the 
forceps  used — axis-traction  forceps  should  always  be  employed — 
something  also  upon  the  predilection  of  an  individual  operator  for 
one  operation  or  the  other,  and  his  consequent  skill  in  the 
performance  of  it.  Version  is  an  operation  performed  in  the 
interest  of  the  child,  and  it  should  not  therefore  be  chosen  if  the 
child  is  dead.  If  the  foetal  heart  has  ceased  to  be  heard,  version 
should  generally  be  rejected,  if  forceps  have  failed ;  for,  although 
the  foetus  may  be  still  just  alive,  it  will  hardly  have  vitality  enough 
to  survive  the  difficult  passage  of  a  contracted  brim.  If  there  is 
still  greater  certainty  of  the  death  of  the  child,  no  prolonged  or 
very  powerful  effort  should  be  made  even  with  forceps,  but  early 
resort  should  be  had  to  craniotomy. 

The  statistics  of  Guy's  Hospital  Charity  afford   evidence   how 


Anomalies  of  the  Pelvis.  747 

much  depends  upon  the  use  of  an  efficient  instrument.  Thus  in 
the  six  years  1863—1869  deUvery  was  effected  by  forceps  or 
version  in  20  cases  of  labour  protracted  in  consequence  of  pelvic 
contraction,  in  which  the  head  was  arrested  high  above  the  brim. 
In  8  of  these  version  was  chosen  as  the  primary  operation,  and 
the  children  were  saved  in  7  out  of  the  8.  In  12  cases  forceps 
were  chosen  for  the  primary  operation.  In  7  out  of  the  12  delivery 
was  effected  by  their  means,  and  3  of  the  7  children  were  living. 
In  the  remaining  5  delivery  was  effected  by  version  after  forceps 
had  failed,  and  3  of  the  5  children  were  living.  During  these  six 
years  a  pair  of  long  curved  forceps  (Lever's)  was  in  use,  but  these 
were  rather  short  in  the  handles,  and  pliant  in  the  blades. 

At  the  end  of  the  six  years  a  new  pair  of  forceps  was  procured, 
otherwise  similar  in  shape,  but  having  longer  handles,  and  more 
unyielding  in  the  blades.  During  the  next  six  years  delivery  was 
effected  by  forceps  or  version  in  18  similar  cases,  in  all  of  which 
forceps  were  chosen  for  the  primary  operation.  In  17  cases  out  of 
the  18  delivery  was  effected  by  them,  and  15  of  the  children  were 
living.  In  the  remaining  case  version  was  successful  after  forceps 
had  failed,  but  the  child  was  still-born.  Version  was  performed  in 
other  instances  after  the  failure  of  forceps,  but  had  to  be  followed 
up  by  craniotomy.  There  have,  however,  been  a  few  cases  since  the 
above  date,  in  which  a  living  child  has  been  delivered  by  version 
after  even  the  more  efficient  forceps  had  failed. 

Thus  in  delivery  by  the  more  efficient  forceps  88-1  per  cent,  of 
the  children  were  saved,  a  better  percentage^  than  the  average  per- 
centage in  low  forceps  cases  in  the  same  charity  ;  in  delivery  by 
version  71*4  per  cent.  Among  the  24  mothers  delivered  by  forceps, 
there  were  no  deaths  ;  among  the  14  delivered  by  version,  there  were 
two  deaths.  The  38  cases  above  enumerated,  together  with  15  only 
of  craniotomy,  comprise  all  the  cases  of  most  considerable  dispro- 
portion between  the  foetus  and  the  pelvis  out  of  23,591  deliveries. 
These  statistics  show  that  the  use  of  forceps  in  contracted  pelves  is 
superior  in  safety  to  version,  and  the  same  conclusion  is  confirmed 
by  the  report  of  the  Guy's  Hospital  Charity  for  the  years  1875— 
1885.  Forceps  were  used  at  the  brim  92  times  ;  6  of  the  mothers 
died,  and  18  of  the  children.  Version  was  performed  for  various 
reasons  when  the  head  was  at  the  brim  in  33  cases,  out  of  which  5 
of  the  mothers  and  29  of  the  children  died.  It  must  be  stated, 
however,  that,  in  10  of  the  version  cases,  forceps  had  been  previously 
tried  in  vain. 

1  Out  of  the  total  number  of  forceps  cases  the  percentage  of  children  saved  was 
76-9, 


74^  The  Practice  of   Midwifery. 

The  following  comparisons  will  further  show  the  gain  as  regards 
foetal  mortality  in  contracted  pelves  from  the  modern  improvement 
in  midwifery  practice.  The  improvement  in  question  probably 
consists  mainly  in  the  employment  of  longer  and  more  unyielding 
forceps  than  it  was  formerly  thought  safe  to  use,  and  in  a  less 
reluctance  to  employ  them  when  the  head  is  high  in  the  pelvis. 
In  the  Guy's  Hospital  Charity,  between  1853  and  1854,  craniotomy 
cases  were  3-6  per  1,000 ;  between  1854  and  1863  they  were 
reduced  to  1-2  per  1,000 ;  between  1863  and  1875  they  were  further 
reduced  to  0"7  per  1,000,  or  more  than  fivefold  in  about  forty  years. 
In  the  following  ten  years,  1875—1885,  they  remained  about  the 
same,  namely,  0-9  per  1,000,  so  that  the  minimum  possible  had 
probably  already  been  attained  in  1863 — 1875. 

The  use  of  axis-traction  forceps  and  of  Walcher's  position  (see 
Chapter  XXXIII.)  undoubtedly  enlarges  still  somewhat  further  the 
scope  of  extraction  by  forceps  in  contracted  pelves,  both  in  com- 
parison with  version  and  with  craniotomy.  But  it,  perhaps,  can 
hardly  be  anticipated  that  material  advance  will  be  gained  on  the 
results  of  the  Guy's  Charity  as  quoted  above,  both  as  regards  the 
extreme  rarity  of  resort  to  craniotomy,  and  the  successful  results, 
both  to  mothers  and  children,  of  extraction  by  forceps  in  the  con- 
siderable degrees  of  pelvic  contraction.  It  should  be  mentioned 
that  although  forceps  have  been  used  very  sparingly  in  the  Guy's 
Charity  (only  once  in  197  deliveries  from  1863  to  1875 ;  once  in  93 
deliveries  from  1875  to  1885),  it  has  been  the  practice  not  long  to 
delay  the  operation  when  considerable  pelvic  contraction  is 
recognised.  That  the  foetal  mortality  in  forceps  operations  in  con- 
tracted pelves  depends  very  largely  upon  the  actual  degree  of 
contraction  of  the  pelvis-  is  well  shown  by  the  results  given  by 
Munro  Kerr.^  In  39  cases  with  a  conjugata  vera  of  3  inches,  the 
foetal  mortality  after  delivery  with  forceps  was  46  per  cent. ;  in 
52  cases  with  a  conjugata  vera  of  3^  inches,  23  per  cent. ;  and  in 
39  cases  with  a  conjugata  vera  of  3 J  inches  it  was  15  per  cent. 

The  average  transverse  diameter  of  the  incompressible  base  of 
the  skull  is  about  3  inches.  Hence,  allowing  a  little  for  the  soft 
parts,  it  cannot  be  expected,  as  a  rule,  that  a  living  child  at  full 
term  will  be  delivered  with  a  conjugate  diameter  much  under 
3f  (8'5  cm.)  inches.  In  exceptional  cases,  no  doubt,  a  full-term 
child  is  delivered  with  a  conjugate  of  2f  (7  cm.)  inches  by  forceps, 
version,  or  sometimes  even  by  the  natural  powers.  Thus  in  a  case 
in  the  Guy's  Hospital  Charity,  where  the  patient  was  at  term  in 
her   second   pregnancy  at  the   age  of   24,  craniotomy  had  to   be 

1  Munro  Kerr,  Operative  Midwifery,  1908,  p.  366. 


Anomalies  of  the  Pelvis.  749 

performed,  with  the  head  arrested  high  above  the  brim,  and  the 
conjugate  diameter  was  estimated  at  not  more  than  2f  inches. 
But  at  her  first  confinement  she  had  been  dehvered  spontaneously 
of  a  living  child  after  24  hours'  labour. 

Hence  version  should  never  be  performed  with  a  conjugate  under 
2f  (7  cm.)  inches,  nor  with  one  under  3i  (8  cm.)  inches  if  there 
is  evidence  that  the  head  is  large.  No  prolonged  efforts  to 
extract  with  forceps  should  be  made  with  a  conjugate  less  than 
3f  (8'5  cm.)  inches.  With  a  conjugate  under  2|  (7  cm.)  inches, 
the  choice  will  be  between  craniotomy  and  Caesarean  section. 
With  a  conjugate  from  2f  (7  cm.)  inches  upward,  there  is  the 
alternative  of  symphysiotomy  or  pubiotomy  if  the  child  cannot  be 
extracted  by  forceps. 

In  the  case  of  the  generally  contracted  pelvis,  extraction  by 
forceps  is  always  preferable  to  version.  If  forceps  fail,  recourse 
must  be  had  to  craniotomy,  symphysiotomy,  or  pubiotomy,  and  not 
to  version.  The  difficulty  here  does  not  lie  mainly  in  the  transverse 
diameters  of  the  head.  Hence  there  are  neither  the  disadvantages 
in  the  use  of  forceps,  nor  the  advantages  in  version,  which  exist  in 
the  flattened  pelvis.  Moreover,  after  version,  the  extended  head 
would  j)robably  find  insufficient  room  for  its  long  diameter  in  any 
diameter  of  the  pelvis.  The  generally  contracted  pelvis  not  unfre- 
quently  gives  occasion  for  craniotomy,  even  when  the  conjugate 
diameter  is  as  much  as  3f  (8*5  cm.)  inches.  In  the  generally 
contracted  pelvis  more  advantage  is  gained  by  symphysiotomy  or 
pubiotomy  than  in  the  flattened  pelvis,  because  in  this  case  a  great 
part  of  the  difficulty  lies  in  the  transverse  diameter,  which  is  much 
more  increased  by  these  operations  than  the  antero-posterior. 

Extraction  of  the  After -coming  Head. — In  the  extraction  of-  the 
after-coming  head  more  assistance  to  nature  is  generally  required 
than  in  primary  pelvic  presentations,  with  a  normal  pelvis.  Before 
the  shoulders  engage  in  the  brim,  it  is  well  to  pass  the  hand  into 
the  vagina,  and  make  sure  that  the  arms  do  not  become  extended 
in  the  brim,  by  the  side  of  the  head,  drawing  them  down,  if 
necessary,  over  the  chest.  When  the  head  engages  in  the  brim, 
extraction  must  be  effected  quickly  if  the  child  is  to  be  saved. 
The  legs  may  be  grasped,  wrapped  in  a  napkin,  and  traction  made 
nearly  in  the  axis  of  the  brim.  At  first,  just  as  the  head  is  entering 
the  brim,  the  direction  of  traction  should  be  a  little  more  forward 
than  this,  in  consequence  of  the  "curve  of  the  false  promontory." 
In  case  of  doubt,  various  directions  of  traction  may  be  tried  in  a 
tentative  way,  but  not  to  the  extent  of  making  a  "  pendulum  move- 
ment," which  might  injure  the  neck,  or  rub  the  head  backward  and 


750  The  Practice  of   Midwifery. 

forward  against  the  brim.  Advantage  may  also  be  gained  by 
having  an  assistant  to  press  down  the  head  from  the  abdomen. 

If  the  head  will  not  pass,  it  will  generally  be  found,  on  passing 
up  the  hand  to  examine,  that  it  is  too  much  extended.  There  are 
two  ways  of  overcoming  this  and  promoting  flexion.  The  first  is  to 
incline  the  direction  of  traction  as  much  as  possible  toward  the  side 
of  the  pelvis  to  which  the  occiput  is  directed.  If  the  line  of  traction 
can  thus  be  made  to  pass  between  the  forehead  and  the  diameter 
most  tightly  grij^ped,  descent  of  the  forehead  more  than  the  occiput, 
and  therefore  flexion  of  the  head,  will  be  promoted.  The  pressure 
of  the  lateral  pelvic  wall  against  the  occiput  also  forms,  with  the 
lateral  component  of  the  traction,  a  "couple,"  or  pair  of  equal  and 
o|)posite  forces,  which  aids  the  same  effect. 

Jaw  Traction. — Another  still  more  effective  expedient,  and  one 
which  may  be  combined  with  the  former,  is  that  of  jaw  traction, 
which  often  ma}^  turn  the  scale  in  favour  of  the  child  in  a  head- 
last  case.  It  has  the  advantage  that  it  not  only  promotes  flexion, 
since  the  maxillary  joint  is  generall}^  slightly  anterior  to  the 
diameter  gripped  in  the  conjugate,  but  increases  the  force  of 
extraction  without  increasing  the  dangerous  tension  applied  to 
the  neck.  The  index  finger  should  be  placed  on  the  edge  of  the 
lower  maxilla,  and  the  jaw  drawn  downward  at  the  same  moment 
that  traction  is  made  upon  the  legs  with  the  other  hand.  Care 
must  be  taken  that  the  finger  is  not  passed  too  far  back,  so  as  to 
injure  the  floor  of  the  mouth  or  the  larynx.  Since  a  certain 
amount  of  injury  may  be  done  to  the  jaw,  and  the  child's  power 
of  sucking  thereby  impaired,  the  expedient  should  not  be  used 
until  simple  traction  has  been  tried  and  failed. 

In  laboratory  experiments  on  the  amount  of  traction  which 
could  be  placed  on  the  lower  jaw  without  causing  injury, 
Matthews  Duncan  ^  found  that,  in  several  instances,  up  to  a 
weight  of  56  lb.,  no  obvious  injury  was  produced.  In  one  case, 
a  crack  was  heard  at  28  lb.  It  thus  appears  that,  in  many  cases, 
an  additional  amount  of  force  can  thus  be  obtained  without 
serious  injury  to  the  child,  equal  to  more  than  one-half  of  that 
which  can  be  safely  applied  through  the  neck  (see  note,  p.  742). 
The  additional  amount  of  force  thus  obtained  is  generally  of  more 
importance  than  the  flexion.  It  is  not,  indeed,  an  actual  flexion 
which  can  be  expected,  but  only  a  limitation  of  extension  ;  for 
the  traction  by  the  spine  will  often  have  greater  effect  in  causing 
extension  than  the  jaw  traction  in  causing  flexion,  if  the  diameter 

1  "On  Traction  by  the  Lower  Jaw  in  Head-last  Cases,"  Trans.  Obst.  Soc,  London, 
1878,  VoL  XX.,  p.  61, 


Anomalies  of   the  Pelvis.  751 

engaged  in  the  conjugate  is  the  one  most  tightly  gripped.  The 
jaw  traction,  however,  will  limit  the  amount  of  extension  pro- 
duced to  that  degree  from  which  it  results  that,  not  the  direction 
of  the  spinal  traction,  but  that  of  the  resultant  of  the  spinal 
traction  and  jaw  traction,  passes  through  the  diameter  of  the 
head  most  tightly  gripped.  The  result  will  probably  be  to  keep 
the  head  in  moderate  extension,  so  that  only  the  fronto-occipital, 
and  not  a  diameter  nearly  approaching  to  the  mento-occipital,  or 
maximum  vertico-mental,  is  thrown  across  the  transverse  diameter 
of  the  pelvis.  The  inclination  of  the  tractile  force  toward  the 
side  where  the  occiput  lies,  described  on  p.  749,  may  materially 
aid  in  aiding  the  descent  of  the  forehead.  It  is  to  be  remembered 
also  that,  when  the  transverse  diameter  of  the  pelvis  is  large  in 
proportion  to  the  head,  it  may  allow  room  for  the  long  diameter 
of  the  head,  even  in  the  position  of  maximum  extension  likel}^ 
to  be  attained,  and  then  the  additional  traction  force  is  alone 
of  value. 

The  mode  of  extracting  the  head  through  the  pelvis  and  vaginal 
outlet  has  already  been  described  (pp.  359 — 364).  If  its  passage 
is  resisted  by  the  pelvic  outlet,  as  may  be  the  case  in  the 
uniformly  contracted  pelvis,  jaw  traction  may  be  used  in  the  same 
way  as  at  the  brim.  It  will  rarely  be  required  to  overcome  the 
resistance  of  soft  parts  only. 

Choice  hettveen  Craniotomy  and  Ccssarean  Section. — In  the  more 
moderate  degrees  of  contraction,  craniotomy  is  an  operation 
involving  very  little  risk  to  the  mother.  If  bad  results  follow, 
they  are  generally  due  rather  to  the  previous  prolongation  of 
labour,  or  the  efforts  to  extract  a  living  child  by  forceps  or 
version,  than  to  the  operation  itself,  provided  that  it  has  been 
IDerformed  skilfully.  In  the  severer  degrees  of  contraction,  how- 
ever, the  case  is  different,  especially  when  the  disproportion  is  so 
great  that  there  is  much  difficulty  in  extracting  the  body  as  well 
as  the  head  of  the  foetus  through  the  brim.  In  these  severer 
degrees  of  flattening,  the  pelvis  is  almost  always  rachitic,  and 
generally  contracted  as  well  as  flattened,  so  that  the  want  of  space 
in  the  transverse  diameter  seriously  increases  the  difficulty  of  the 
operation.  Under  these  circumstances  it  is  one  of  considerable 
risk  to  the  mother.  According  to  Perry,  craniotomy  in  America, 
in  70  cases  of  pelves  having  a  conjugate  measuring  2 J  inches  and 
under,  gave  a  mortality  of  38*5  per  cent. 

The  recent  improvements  in  Ceesarean  section  have  greatly 
enlarged  its  field  as  compared  with  craniotomy.  The  general 
mortality  is  now  less  than  10  per  cent.,  and   some   expert   and 


752  The  Practice  of   Midwifery. 

experienced  operators  have  obtained  still  more  favourable  results. 
In  385  operations  by  ten  operators,  collected  by  Whitridge 
Williams,  there  were  only  23  deaths,  a  mortality  of  6'87  per  cent. 
Deducting  cases  infected  before  operation,  he  arrives  at  a  corrected 
mortality  of  4*06  per  cent. 

Munro  Kerr  has  collected  172  cases  operated  upon  by  different 
English  operators,  with  19  deaths,  and  if  to  these  we  add  the  37 
cases  published  by  Gow^  without  a  death,  we  have  a  total  of  209 
cases  with  19  deaths,  or  a  maternal  mortality  rate  of  9  per  cent. 

Leopold  has  recorded  229  cases  with  16  deaths,  or  a  mortality 
of  7  per  cent.,  and  Schauta  has  recorded  158  cases,  with  a  mortality 
of  5  per  cent. 

It  is  sometimes  stated  that  the  mortality  of  embrj^otomy  in  all 
but  extreme  degrees  of  contraction  is  or  ought  to  be  almost  nil ; 
but  there  do  not  appear  to  be  any  statistics  on  an  extensive  scale 
to  show  this. 

In  statistics  from  any  given  institution  the  mortality  of  Caesarean 
section  is  generally  greater  than  that  of  embryotomy ;  but  statistics 
of  embryotomy  do  not  show  a  greater  or  even  so  great  a  safety 
to  the  mothers  as  those  of  Caesarean  section  in  the  hands  of  the 
most  successful  operators. 

The  statistics  collected  by  Meriwether^  show  a  maternal  mortality 
of  8'1  per  cent,  for  embrj^otomy,  compared  with  one  of  5*1  per 
cent,  to  the  mothers  (3'8  per  cent,  excluding  cases  previously 
infected),  and  4*7  per  cent,  to  the  children  in  Cesarean  section. 
In  the  Guy's  Hospital  Lying-in  Charity,  for  ten  years  up  to  1901, 
there  were  8  deaths  in  33  embryotomies,  or  9  per  cent.  At  the 
Eotunda  Hospital,  Dublin,  from  1896  to  1900,  there  was  1  death 
in  6  embryotomies,  or  16'6  per  cent.  In  47  embryotomies  recorded 
by  Gusserow  ^  there  were  3  deaths,  or  6"3  per  cent.  In  63  cases 
of  craniotomy  recorded  by  Munro  Kerr  there  were  6  deaths,  or  a 
mortality  of  12*6  per  cent.,  but  nearly  all  these  cases  were  infected 
at  the  time  of  oj)eration.  Even  delivery  by  forceps  or  version 
through  a  markedly  contracted  pelvis,  has  a  mortality  little  if  at 
all  less  than  the  most  favourable  statistics  of  Caesarean  section. 
The  statistics  of  the  Johns  Hopkins  Hospital,  Baltimore,  showed  a 
maternal  mortality  of  2*8  per  cent,  for  all  operations  for  delivery  in 
contracted  pelvis,  and  one  of  3  per  cent,  for  delivery  by  Cassarean 
section. 

It  may  be  inferred  that  the  field  of  Caesarean  section  may  now 

1  Csesarean  Section,  Harveian  Lecture,  1907. 

2  Amer.  Journ.  of  Obst.  1901,  XLIV.,  pp.  207—209. 

3  Berl.  Klin.  Woch.,  1902,  No.  6  et  secj^. 


Anomalies  of  the  Pelvis.  753 

be  justly  extended  at  the  expense  of  embryotomy  in  cases  of  con- 
tracted pelvis,  and  that  a  patient  at  or  near  the  full  term  of 
pregnancy  may  rightly  be  advised  to  undergo  Caesarian  section,  if 
it  can  be  performed  by  an  experienced  operator  in  favourable 
surroundings,  in  all  cases  in  which  it  is  likely  that  the  delivery  of 
a  living  child  through  the  pelvis  would  be  impossible,  or  even 
involve  very  serious  difficulty. 

Induction  of  premature  labour,  however,  in  cases  for  which  it  is 
applicable,  involves  a  less  mortality  to  the  mothers,  and  should 
therefore  be  chosen  in  preference.  For  the  maternal  mortality  is 
estimated  at  not  more  than  1  per  cent.  The  mortality  to  the 
children,  however,  may  be  as  much  as  30  per  cent.,  and  some 
reckon  it  as  high  as  50 — 60  per  cent.,  including  those  children 
who  do  not  survive  more  than  a  few  months. 

Some  writers  have  claimed  that  embryotomy  must  now  be 
regarded  as  a  murderous  oi)eration  because  it  destroys  the  child, 
and  that  Cfesarean  section  may  displace  it  altogether ;  but  this 
conclusion  is  not  as  yet  justified,  nor  does  it  appear  likely  to  be  so. 
For  many  embryotomies  are  performed  in  cases  in  which  difficulty 
is  met  with  unexpectedly,  in  which  there  has  been  no  question  of 
arranging  for  Caesarean  section  beforehand,  and  in  which  attempts 
have  been  made  to  deliver  by  forceps,  or  the  child  is  dead.  In  these 
circumstances  the  mortality  of  Cesarean  section  would  be  far 
greater  than  the  minimum  mortality,  especially  if  the  surroundings 
were  unfavourable.  Even  the  interest  of  foetal  life,  therefore,  may 
demand  embryotomy,  that  the  mother  may  have  the  better  chance 
of  surviving  to  bear  more  children. 

It  is  possible  to  extract  through  the  pelvis  after  craniotomy 
with  a  conjugate  diameter  as  small  as  2^  or  even  2  inches,  if  there 
is  a  fair  transverse  diameter,  and  room  at  the  sides  of  the  sacral 
promontory.  But  the  risk  of  the  operation  is  then  so  considerable 
that  a  skilled  operator  should  rather  choose  Caesarean  section,  even 
after  prolonged  labour,  if  the  surroundings  are  not  too  unfavourable, 
with  a  conjugate  less  than  2|  inches.  In  these  circumstances,  as 
the  patient  is  very  likely  to  be  infected,  probably  the  best  results 
will  be  obtained  by  the  performance  of  extraperitoneal  Caesarean 
section,  the  formation  of  a  utero-abdominal  fistula,  as  recom- 
mended by  Sellheim,  or  the  removal  of  the  uterus. 

Symphysiotomy  and  Pubiotomy. — Tbe  improvement  which  has 
taken  place  of  recent  years  in  the  results,  both  as  regards  the 
mothers  and  the  children,  of  the  operations  of  symphysiotomy  and 
pubiotomy,  and  especially  the  introduction  of  the  subcutaneous 
method  of  performing  the  latter  operation,  renders  it  likely  that 

M.  48 


754  The  Practice  of   Midwifery. 

they  will  be  practised  to  a  much  greater  extent  in  the  future  in 
this  country  than  has  been  the  case  in  the  past. 

In  the  last  edition  of  this  book  the  best  results  of  symphysiotomy, 
those  of  Pinard,  showed  a  death-rate  of  12  per  cent,  for  the  mothers 
and  15  per  cent,  for  the  children,  while  in  a  recent  table  of  275 
cases  quoted  by  Munro  Kerr  the  maternal  mortality  is  6*5  per  cent, 
and  the  foetal  10  per  cent.,  a  diminution  of  the  maternal  death-rate 
by  nearly  50  per  cent.  Even  better  results  than  these  have  been 
obtained  after  pubiotomy.  Thus  Leopold  has  operated  in  60  cases 
with  no  maternal  deaths,  Bumm  in  53  cases  with  1  death, 
and  Burger  in  30  cases  with  no  death,  or  a  total  of  143  cases  with 
1  death,  a  maternal  mortality  of  '69  per  cent.  In  Leopold's  60 
cases  four  of  the  children  died,  or  6'6  per  cent.,  and  in  225  cases 
collected  by  Doederlein  the  foetal  death  was  also  6*6  per  cent. 
This  mortality,  both  maternal  and  fcetal,  is  considerably  less 
than  that  of  symphysiotomy,  and  compares  very  favourably  with 
that  of  any  other  method  of  delivery  in  contracted  pelves. 

It  must  be  remembered,  however,  that  these  results  are  those 
of  expert  operators  in  good  surroundings,  and  they  represent  the 
best  results  which  can  be  obtained  by  the  operation  of  pubiotomy. 
It  must  also  be  remembered  that  the  morbidity  of  these  cases  is 
very  high.  Thus  more  than  half  of  Bumm's  cases  were  feverish 
during  the  puerperium.  The  risk  of  tears  and  lacerations  is  also 
considerable :  in  41  of  his  cases  delivered  artificially  there  were 
7  lacerations  of  the  bladder  and  urethra,  and  in  19  there  were 
tears  of  the  vagina  and  vulva  in  the  neighbourhood  of  the  section 
of  the  bone.  On  the  other  hand,  of  the  53  women  34  were  seen 
subsequently,  and  all  were  well  enough  to  do  their  work.  There 
also  seems  to  be  some  evidence  in  favour  of  the  view  that  the 
pelvis  remains  permanently  enlarged  after  the  operation  of 
pubiotomy,  at  any  rate  in  some  cases. 

Pubiotomy  or  symi)hysiotomy  is  only  to  be  carried  out  after  full 
dilatation  of  the  soft  parts  has  occurred  and  in  cases  of  moderate 
contraction  of  the  pelvis  when  one  or  two  attempts  with  forceps 
in  Walcher's  position  have  failed  to  deliver  the  patient,  and  the 
disproportion  between  the  head  and  the  brim  seems  too  great  to  be 
overcome  by  the  natural  forces.  In  all  cases  after  the  operation 
has  been  performed  labour  should  be  allowed  to  terminate  naturally. 
The  operation  therefore  may  be  suggested  to  the  patient  and  her 
husband  as  one  which,  at  a  slightly  increased  risk  to  the  mother, 
offers  a  much  better  chance  of  saving  the  child  than  version,  forceps 
having  failed  or  being  considered  inadvisable,  provided  that  it  can 
be  performed  in  good  surroundings,  and  in  conditions  which  allow 


Anomalies  of  the  Pelvis.  755 

of  the  dangerous  sequelae  which  may  follow  it  being  properly  and 
promptly  dealt  with. 

It  should  only  be  practised  as  a  general  rule  in  pelves  with  a 
conjugate  diameter  measuring  from  3  inches  (7"5  cm.)  up  to  3| 
(9  cm.),  and  is  more  suitable  for  multiparas  than  primiparse.^ 

Induction  of  Premature  Labour. — By  the  induction  of  premature 
labour,  two  advantages  are  obtained :  first,  the  smaller  size  of  the 
head ;  and  secondly,  the  more  yielding  consistency  of  the  bones, 
allowing  the  diameter  engaged  in  the  conjugate  to  undergo  a 
greater  reduction  from  pressure.  Benefit  is  thus  gained  both  for 
the  mother  and  the  child.  Labour  is  less  severe  for  the  mother, 
and  there  is  a  greater  chance  of  a  living  child  being  born  in  those 
cases  in  which  such  a  result  is  not  probable  at  the  full  term. 

In  the  slighter  degrees  of  contraction,  in  which  there  is  a  fair 
prospect  of  a  living  child  being  born  alive  at  full  term,  either 
spontaneously  or  with  the  aid  of  forceps  or  version,  it  is  better 
not  to  induce  labour,  for  the  amount  of  interference  necessary  for 
the  induction  of  labour  does  somewhat  increase  the  risk  to  the 
mother,  although  not  to  such  a  great  degree  as  a  severe  instru- 
mental delivery  would  do.  In  the  flattened  pelvis,  the  scope  of 
the  operation  lies  chiefly  among  conjugate  diameters  varying 
from  3f  down  to  3  inches.  In  the  generally  contracted  pelvis,  it 
may  be  called  for  even  with  a  conjugate  above  3|  inches.  Since, 
however,  the  average  size  of  the  child  varies  in  different  women, 
and  the  transverse  measurements  of  the  pelvis  cannot  be  exactly 
estimated,  the  history  of  previous  labours,  when  the  patient  is  not 
a  primipara,  gives  even  more  information  than  the  measurement 
of  the  pelvis.  As  a  general  rule,  when  craniotomy  has  been 
required  in  a  former  labour  on  account  of  disproportion  between 
the  fcetus  and  the  pelvis,  or  when  the  child  has  been  still-born,  in 
consequence  of  delay  within  the  pelvis,  even  though  delivered 
whole  by  forceps  or  version,  premature  labour  should  be  induced 
in  subsequent  pregnancies.  A  careful  examination  should  be 
made,  if  necessary  with  an  anaesthetic,  and  the  exact  relation 
between  the  size  of  the  child's  head  and  that  of  the  pelvis  deter- 
mined, and  then,  if  it  is  thought  advisable,  at  the  proper  time 
the  induction  should  be  commenced.  A  primipara  with  a  con- 
jugate of  3§  inches  should  be  allowed  to  go  to  full  term.  If  the 
conjugate  measures  less  than  this  or  the  child  is  unduly  large, 
premature  labour  should  be  induced.  In  order  that  the  condition 
may  be  recognised  before  the  onset  of  labour,  as  a  general  rule  all 
pregnant  women  should  be  examined  by  the  abdomen  at  about  the 

1   I'.lacker,  Luncct,  March  ID,  I'Jlo,  p.  778. 

48—2 


756  The  Practice  of   Midwifery. 

thirtieth  week  of  pregnancy,  in  order  that,  if  they  are  primiparae, 
the  external  pelvic  measurements  may  be  taken,  and,  if  necessary, 
the  internal  measurements,  and  that,  if  they  are  multiparse  with  a 
history  of  difficulty  in  their  previous  labours,  after  examination 
a  decision  may  be  come  to  as  to  the  correct  treatment  and  as  to  the 
necessity  or  not  for  the  induction  of  premature  labour.  If  the 
patient  is  a  multipara,  most  reliance  should  be  placed  upon  the 
history  of  the  more  recent  labours,  since,  in  contracted  pelvis,  the 
difficulty  is  apt  to  increase  progressively  with  increased  size  of  the 
children.  If  a  female  child  only  has  been  with  difficulty  extracted 
alive  at  term,  it  may  sometimes  be  desirable  to  induce  premature 
labour  on  a  subsequent  occasion,  since  the  difficulty  is  likely  to  be 
greater  if  the  next  child  proves  to  be  a  male. 

It  must  be  remembered  that  the  mortality  among  the  children 
born  after  the  induction  of  premature  labour  in  hospital  practice  is 
very  high,  and  especially  so  in  the  higher  degrees  of  contraction  of 
the  pelvis,  for  example  with  a  conjugate  of  3  to  3 J  inches. 
According  to  Bar,^  the  mortality  to  children  after  induction  of 
premature  labour  is  with  a  conjugate  of  6  to  7  cm.  (2"4  to  2"75 
inches)  80  per  cent. ;  with  7  to  8  cm.  (2*75  to  3'15  inches)  53  per 
cent.;  with  8  to  9  cm.  (3*15  to  3-5  inches)  12  per  cent. ;  with  9  to 
10  cm.  (3"5  to  3'95  inches)  8*6  per  cent. 

Munro  Kerr  records  a  foetal  mortality  of  44  per  cent,  with  a  conju- 
gate of  3  inches  (7*5  cm.),  33  per  cent,  with  a  conjugate  of  3J  inches 
(81  cm.),  and  25  per  cent,  with  a  conjugate  of  3J  inches  (8'7  cm.). 

Of  84  cases  treated  by  Leopold  1  mother  died  of  septic  infec- 
tion, while  13  of  the  children,  or  15'4  per  cent.,  were  born  dead, 
and  13  of  them  died  before  leaving  the  hospital,  a  total  mortality 
of  more  than  30  per  cent.  Of  the  remainder  24  died  within  the 
first  3'ear,  but  this  is  not  above  the  average  mortality  of  infants  of 
that  age.  Leopold^  does  not  advise  the  induction  of  premature 
labour  in  generally  contracted  pelves  with  a  conjugate  diameter  of 
less  than  3  inches  (7"5  cm.). 

A  good  many  obstetricians  at  the  present  day  disapprove  of  the 
induction  of  premature  labour  on  the  ground  of  statistics  apparently 
showing  the  mortality  to  children,  as  well  as  to  mothers,  to  be 
greater  in  cases  of  premature  labour  than  in  those  of  labour  at  the 
full  term  in  contracted  pelves.  Some  of  these  statistics  are 
fallacious,  because  they  include  in  the  latter  class  the  commoner 
and  slighter  degrees  of  pelvic  contraction,  in  which  it  is  admitted 
that  the  induction  of  labour  is  unnecessary  and  inexpedient.    When 

1  Bar,  L'Ostetrique,  March,  1902. 

2  Leopold  and  Konrad,  Arch.  f.  Gyniik.,  1907,  Bd.  81,  p.  G48. 


Anomalies  of  the  Pelvis.  757 

different  labours  are  compared  in  the  same  woman,  in  whom  pelvic 
contraction  is  considerable,  the  advantages  of  the  induction  of 
labour  are  strikingly  exhibited.  Thus  Milne^  records  38  induced 
premature  labours  in  6  women  without  any  maternal  death,  in 
which  35  children  were  born  alive.  In  12  labours  at  term  of  the 
same  6  women,  only  1  child  was  born  alive. 

Dohrn,^  too,  records  the  case  of  19  women  among  whom  only  4 
children,  or  9"7  per  cent.,  were  born  alive  as  the  result  of  41 
deliveries  at  full  term,  while  among  the  same  women  in  25 
labours  after  the  induction  of  premature  labour  15,  or  60  per  cent., 
of  the  children  were  born  alive. 

Again,  Von  Herff^  records  31  premature  labours  with  a  death- 
rate  of  20  per  cent,  among  the  children,  while  in  61  deliveries 
at  full  term  among  the  same  patients  50*82  per  cent,  of  the  children 
were  born  dead. 

With  a  conjugate  less  than  3  inches  there  is  practically  little 
chance  of  a  living  child  being  secured  even  by  induction  of  labour. 
There  is,  however,  just  a  possibility  of  it  with  a  conjugate  a  little 
under  3  inches,  provided  the  transverse  diameter  is  large  in  pro- 
portion, and  the  pelvis  is  reniform,  with  ample  space  at  the  sides 
of  the  sacrum.  In  these  circumstances  a  trial  of  the  effect  of 
induction  may  be  made.  When  the  contraction  is  so  great  that  a 
living  child  cannot  be  hoped  for,  that  is  to  say,  in  most  pelves 
with  a  conjugate  less  than  3  inches,  it  is  better  to  let  the  j)atient 
go  to  full  term,  even  if  Csesarean  section  is  refused.  The  extra 
disturbance  and  risk  involved  in  the  induction  of  labour  are 
thereby  avoided.  In  extreme  forms  of  contraction,  as  with  a  con- 
jugate of  2i-  inches  or  less.  Cesarean  section  will  now  generally  be 
chosen,  if  there  is  an  opportunity  of  arranging  for  its  performance 
by  an  operator  skilled  in  abdominal  surgery. 

Date  for  Induction  of  Labour. — Although  a  child  is  nominally 
regarded  as  viable  at  the  end  of  twenty-eight  weeks,  there  is  so  little 
chance  of  its  surviving  if  born  before  about  the  end  of  the  thirty- 
second  week,  that  it  is  not  worth  while  to  induce  labour  before 
that  time  for  the  sake  of  the  child.  In  choosing  the  exact  time 
in  any  given  case,  regard  should  be  paid,  not  only  to  the  size  of 
the  conjugate  diameter  and  the  size  of  the  foetal  head,  but  to 
the  other  dimensions  and  shape  of  the  pelvis,  to  the  amount  of 
difficulty  found  in  extraction  at  term,  and  still  more  to  the  results 
of  induction  on  any  former  occasion.      Thus,  if  labour  has  been 

1  "  Piemature  Labour  and  Version,"  Edin.  Med.  Journ.,  Vol.  XXI. 

•2  Dohrn,  Arch.  f.  Gynak.,  ]877,  Bd.  12,  p.  53. 

8  Von  Hcrff,  Volkmann's  Samml.  Klin.  Vortrage,  N.  F.,  No.  386,  XIII.,  p.  269. 


758 


The  Practice  of   Midwifery. 


induced  before,  say  at  the  thirty-sixth  week,  and  the  child  has 
been  lost  through  delay  at  the  brim,  it  should  be  induced  earlier 
on  the  next  occasion.  If  it  has  been  induced,  say  at  the  thirty- 
second  week,  and  the  child  has  passed  very  easily,  the  patient  may 
be  allowed  another  time  to  go  a  little  longer,  especially  if  the 
former  child  did  not  prove  strong  enough  permanently  to  survive. 

So  far  as  the  conjugate  diameter  can  be  taken  as  an  indication, 
the  following  may  be  given  as  reasonable  rules : — 

With  a  conjugate  of  3J  inches  induce  labour  at  the  end  of  the  36th  week. 


Fig.  370.— Munro  Kerr's  method  of  determining  relative  size  of  fcetal  head 
and  maternal  pelvis. 


A  more  exact  determination  may  be  obtained  by  measuring  the 
size  of  the  foetal  head  in  proportion  to  the  brim  in  the  particular 
case.  Two  or  three  weeks  before  the  date  provisionally  fixed  for 
the  induction,  the  foetus  should  be  examined  by  abdominal  palpa- 
tion by  the  fourth  method  described  at  p.  277.  The  examiner 
ascertains  whether  the  head  is  engaged  in  the  brim,  and,  if  not, 
whether  it  can  be  pressed  down  into  it.  If  he  cannot  determine 
this  by  the  two  hands  used  externally,  one  or  two  fingers  of  the 
right  hand  are  passed  into  the  vagina  to  ascertain  the  level  of  the 


Anomalies  of  the  Pelvis.  759 

head,  while  the  left  hand  is  used  to  press  down  the  head  from  above. 
If  necessary,  the  aid  of  an  assistant  may  be  employed,  to  exercise 
additional  external  pressure.  In  the  case  of  a  fat  patient,  or  one 
intolerant  of  manipulation,  an  ansesthetic  may  be  required. 

The  modification  of  Miiller's  ^  method  introduced  by  Munro 
Kerr^  is  undoubtedly  an  improvement  (see  Fig.  370).  He  employs 
a  cephalic  grip  (Paivlic's  grip)  with  the  left  hand  to  press  the 
head  into  the  pelvis  and  places  the  thumb  of  the  right  hand 
above  the  symphysis  pubis  so  as  to  estimate  the  amount  of  over- 
lapping of  the  head  in  cases  where  it  does  not  descend  into  the 
brim  of  the  pelvis. 

The  examination  is  repeated  at  intervals  of  a  week  or  rather  less. 
As  soon  as  it  becomes  difficult  to  press  the  head  down  into  the 
brim,  the  time  for  induction  has  arrived.  This  method  of  examina- 
tion should  be  employed  in  all  cases  of  contracted  pelvis  to  deter- 
mine the  relation  of  the  size  of  the  foetal  head  to  that  of  the  pelvic 
inlet,  and  is  of  the  utmost  value  not  only  in  determining  the  exact 
date  on  which  to  induce  labour,  but  also  in  enabling  the  practitioner 
to  come  to  a  decision  as  to  the  correct  treatment  to  follow  in  any 
case  of  contracted  pelvis.  Too  much  stress  cannot  be  laid  on  the 
fact  that  in  the  majority  of  cases  the  decision  depends  upon  the 
relation  between  the  size  of  the  head  and  that  of  the  pelvis,  and  not 
upon  the  pelvic  dimensions  alone. 

Induction  of  Abortion. — When  contraction  is  so  great  that  there 
is  no  hope  of  obtaining  a  viable  child,  and  extraction  after  cranio- 
tomy at  full  term  is  likely  to  be  very  difficult  and  dangerous,  it  has 
been  suggested  to  induce  abortion  at  the  earliest  opportunity.  In 
such  cases,  however,  it  is  much  better  for  the  patient  to  go  to  full 
term  and  to  have  Ctesarean  section  performed,  and  be  sterilised  if 
she  demands  it.  Not  only  in  such  a  case  must  the  life  of  the  child 
be  considered,  but  if  abortion  be  procured  pregnancy  may  recur 
quickly  and  the  operation  be  again  required.  Indeed,  it  is  exceed- 
ingly doubtful  if  the  production  of  artificial  abortion  is  ever  justifi- 
able in  these  conditions. 

Treatment  of  Shoulder  and  Transverse  Presentations  in  Contracted 
Pelvis. — In  a  flattened  pelvis,  as  a  rule,  no  attempt  should  be  made 
to  effect  cephalic  version,  for  delivery  of  the  after-coming  head 
will  probably  be  more  easily  effected  ;  and,  if  the  head  were  brought 
to  present,  podalic  version  might  be  called  for  afterwards.  If, 
however,  the  contraction  is  so  great  that  there  is  no  chance  of 

1  Miiller,  "  Uber  das  Einprcssen  der  Kopfes  in  den  Beckenkanal  zu  Diagnostichen 
Zwcckcn,"  Volkrnaiiii's  Hanniil.  Klin.  Vortnige,  188.5,  No.  204. 
'■'  iVIunro  Kerr,  .Jouni.  Obst.  and  (Jyn.  Brit.  Emp.,  1904,  No.  .3,  p.  227. 


760  The  Practice  of   Midwifery. 

saving  the  child,  then  the  head  should  be  brought  to  present  if 
possible,  unless  the  alternative  of  Cesarean  section  is  adopted, 
sinne  in  considerable  contraction,  craniotomy  with  an  after-coming 
head  is  a  more  difficult  and  tedious  operation.  In  the  pelvis 
sequabiliter  justo  minor  also  the  head  should  always  be  brought 
to  present  if  possible. 

Summary  of  Treatment. — Now  that  we  have  discussed  the  various 
methods  of  treating  cases  of  contracted  pelvis,  we  may  summarise 
the  treatment  appropriate  for  the  four  classes  of  pelvis  mentioned 
on  p.  740,  the  foetal  head  being  assumed  to  be  of  normal  size. 

We  will  consider,  for  the  sake  of  clearness,  class  4  first — namely, 
pelves  in  which  delivery  through  the  natural  passages  is  impossible  or 
involves  greater  risk  than  the  performance  of  Caesarean  section. 
This  class  will  include  all  pelves  with  a  conjugate  diameter  equal 
to  or  less  than  2  inches  (5  cm.).  In  these  cases  Cfesarean  section, 
either  the  classical  operation  or  the  extraperitoneal  one,  will  give  the 
best  results,  and  should  be  practised  whether  the  child  is  alive  or  dead. 
If  the  patient  shows  signs  of  infection,  then  the  operation  should  be 
followed  by  removal  of  the  uterus  by  hysterectomy,  or  by  Porro's 
operation,  or  by  the  formation  of  a  utero-abdominal  fistula  as 
recommended  by  Sellheim. 

Class  3  is  that  of  pelves  in  which  a  living  child  cannot  be  born 
with  certainty  at  full  term,  but  in  which  a  child  can  be  extracted 
after  embrj-otomy  without  undue  risk  to  the  mother.  This  will 
include  pelves  with  a  conjugate  diameter  of  2  to  3  inches  (5  to 
7"5  cm.). 

In  these  cases  when  seen  during  pregnancy  Cesarean  section  at 
full  term  should  be  advised.  If  the  patient  is  in  labour  and  the 
conditions  of  the  mother  and  the  child  are  both  good.  Cesarean 
section  will  give  the  best  results.  If  seen  for  the  first  time  late  in 
labour  when  the  condition  of  the  child  is  doubtful  or  it  is  dead,  or 
the  condition  of  the  mother  is  not  satisfactory,  delivery  by 
craniotomy  or  embryotomy  is  indicated. 

Class  1  is  that  of  pelves  in  which  delivery  of  a  living  child  at  full 
term  by  the  natural  powers  may  be  expected.  This  class  will 
include  pelves  with  a  conjugate  diameter  of  3|  inches  (9  cm.)  or 
more.  All  such  cases  should  be  allowed  to  go  to  full  term.  In  the 
very  great  majority  of  them  no  interference  will  be  required,  and 
none  should  be  carried  out  unless  strictly  indicated,  since  spon- 
taneous delivery  gives  the  best  results  for  both  the  mothers  and 
the  children.  If  any  assistance  is  required,  then  axis  traction 
forceps  should  be  employed  or  version  performed  when  indicated. 

Class  2  is  that  of  pelves  in  which  delivery  of  a  living  and  viable 


Anomalies  of  the  Pelvis.  761 

child  is  probable  by  the  induction  of  premature  labour  or  by  other 
means,  but  not  that  of  a  living  child  at  full  term  by  spontaneous 
delivery.  This  class  will  include  pelves  with  a  conjugate  diameter 
between  3  and  3f  inches  (7"5  to  9  cm.).  This  class  of  contracted 
pelvis  is  the  one  about  which  there  is  the  greatest  difference  of  opinion 
among  different  authorities  as  to  the  treatment  to  be  adopted. 

If  the  patient  is  seen  during  her  pregnancy,  no  doubt  the  best 
treatment  in  private  practice  is  the  induction  of  premature  labour 
at  a  date  to  be  determined  by  a  careful  estimation  of  the  relation 
between  the  size  of  the  head  and  that  of  the  pelvis.  In  a  lying-in 
hospital  or  in  the  best  possible  conditions  the  question  of  allowing 
the  patient  to  go  to  full  term  and  then,  if  necessary,  performing 
pubiotomy  or  symphysiotomy  must  be  considered.  It  is  in  this 
degree  of  pelvic  contraction  that  a  sharp  line  of  demarcation  must 
be  made  between  the  treatment  suitable  for  a  patient  in  private 
practice  and  that  for  one  in  a  lying-in  hospital.  In  the  former  case, 
where  possible,  the  induction  of  premature  labour  is  indicated.  If 
the  patient  is  seen  for  the  first  time  in  labour  and  the  condition  of 
the  mother  and  child  is  good,  then  a  sufficient  length  of  time  should 
be  given  to  see  if  spontaneous  delivery  will  not  occur.  For  this 
purpose  there  need  be  no  hesitation  in  allowing  the  second  stage  to 
continue  for  several  hours  provided  that  a  careful  watch  is  kept  on 
the  condition  of  the  mother  and  the  heart  of  the  foetus.  If  it 
becomes  evident  that  spontaneous  delivery  will  not  occur,  then  in 
private  practice  axis  traction  forceps  should  be  applied  to  the  head 
if  it  is  engaged  in  the  brim,  or  if  not  a  cautious  attempt,  with  the 
patient  in  Walcher's  position,  may  be  made  to  pull  it  into  the  brim, 
while  if  this  fails  version  may  be  performed,  since  this  may  succeed 
in  a  small  number  of  cases  where  axis  traction  forceps  fail.  If  the 
child  is  dead  or  it  cannot  be  extracted  after  the  application  of  forceps 
or  the  performance  of  version,  then  there  should  be  no  hesitation  in 
performing  craniotomy.  It  is  better  to  kill  even  a  living  child  than 
to  gravely  endanger  the  mother's  life,  since  there  will  be  every 
chance  of  obtaining  a  living  child  on  a  subsequent  occasion  by  the 
induction  of  premature  labour,  the  performance  of  symphysiotomy 
or  pubiotomy,  or  even  by  Csesarean  section  if  necessary. 

In  lying-in  hospitals  the  plan  of  treatment  already  adopted  with 
marked  success  by  many  obstetricians  will  tend  no  doubt  to  become 
more  and  more  prevalent,  namely  the  performance  of  pubiotomy  in 
preference  to  the  induction  of  premature  labour.  This  practice 
will  especially  api)ly  to  pelves  in  this  class  with  a  conjugate  from 
3  to  3^  inches  (7*5  to  8"7cm.).  In  such  cases  the  patient,  if  she  con- 
sents, will  be  allowed  to  go  to  full  term,  and  after  complete  dilatation 


762  The  Practice  of   Midwifery. 

of  the  cervix  has  occurred  symphysiotomy  or  pubiotomy  will  be  per- 
formed, or,  if  she  refuses  pubiotomy,  Csesarean  section,  as  an  opera- 
tion of  election,  will  give  the  best  results  for  the  mother  and  the 
child.  It  must  always  be  carefully  borne  in  mind  that  pubiotomy 
and  symphysiotomy  are  operations  performed  in  the  interest  of  the 
child,  and  therefore  neither  of  them  should  ever  be  practised  if  the 
life  of  the  child  has  been  at  all  endangered.  For  this  reason  not 
more  than  one  or  two  attempts  should  be  made  to  deliver  with 
forcej)s  if  it  is  intended  to  practise  either  of  these  operations. 

The  line  of  treatment  to  be  followed  in  the  case  of  a  contracted 
pelvis  cannot  be  defined  in  terms  of  the  degree  of  pelvic  contraction, 
and  due  regard  must  always  be  had  to  the  many  other  important 
factors  involved.  Thus  in  coming  to  a  decision  in  any  particular 
case  the  practitioner  must  carefully  consider  whether  his  patient  is 
a  primipara  or  a  multipara,  and  if  the  latter  her  previous  obstetric 
history,  the  duration  of  the  pregnancy,  the  relation  between  the 
size  of  the  head  and  that  of  the  pelvis,  the  surroundings  and  con- 
ditions in  which  her  confinement  will  take  place,  the  character  of 
the  pains,  if  she  is  in  labour,  and  the  kind  of  assistance  he  can,  if 
necessary,  call  to  hishelp. 


Chapter   XXX. 
RARE  FORMS  OF  PELVIC  DEFORMITY. 

The  Triradiate  or  Eostrated  (Beaked)  Pelvis. 

This  form  of  pelvis  is  evidently  due  to  the  pushing  inward 
both  of  the  sacrum  with  the  lumbar  spine  and  the  acetabula  toward 
the  centre  of  the  brim   (see  Fig.  371).     The  bending  takes  place 


Fig.  371. — Triradiate  malacosteon  pelvis  in  extreme  deformity,  viewed  in  the 
axis  of  the  brim. 

earliest  and  most  at  the  weakest  part  of  the  superior  rami  of  the 
pubes,  as  well  as  near  the  junction  of  the  pubes  and  ischium,  and 
it  is  in  this  way  that  the  characteristic  beaked  shape  is  produced 
(see  Fig.  373,  p.  765).  The  shape  of  the  brim  comes  to  resemble  a 
three-rayed  star,  regular  or  irregular,  the  anterior  ray  being 
generally  the  narrowest. 

Causation. — The  triradiate  pelvis  is  most  frequently  the  result 
of  osteo-malacia,  or  moUities  ossium.  This  is  a  disease  extremely 
rare  in  Britain,  and  still  more  so  in  America,  where  insufficient 
feeding  is  less  common.  It  appears  to  be  endemic  in  certain 
districts,  especially  on  the  islands  in  the  Danube,  round  the  region 
of  the  Po  in  Italy,  in  the  valley  of  the  Ehine,  in  some  valleys  of 
Switzerland,  and  in  the  city  of  Vienna.  The  main  cause  seems  to 
be  something  unsuitable  in  food  and  sanitary  conditions,  with 
[)rt>]);i])]y  the  addition  of  some  influence  of  climate  and  locality. 


764  The  Practice  of   Midwifery. 

Evidence  in  favour  of  this  view  is  to  be  found  in  the  fact  that  in 
some  locahties  the  disease  has  disappeared  as  the  result  of 
improvements  in  the  sanitary  and  social  surroundings  of  the 
people. 

Osteo-malacia,  like  rickets,  softens  the  bones,  but  it  differs  from 
rickets  in  that,  almost  invariably,  it  softens  them  after  they  have 
attained  maturity,  softens  them  throughout  instead  of  only  at  the 
growing  portions,  and  softens  them  to  much  higher  dogree. 

Osteo-malacia  occurs  far  more  frequently  in  women  than  in  men 
and  is  especially  associated  with  pregnancy.  This  may  be  explained 
in  some  degree  by  the  expenditure  of  lime-salts  for  the  nutriment 
of  the  fcetus.  It  rarely  occurs  in  a  first  pregnancy,  more  frequently 
after   repeated    childbirth,   is   associated   with   a   high   degree   of 

fertility,  and  is  generally 
recurrent  in  repeated  preg- 
nancies. Usually  it  is  pro- 
gressive, but  sometimes  it  is 
arrested,  and  the  bones 
become  hardened  again  in 
their  abnormal  state.  The 
disease  is  a  form  of  osteo- 
myelitis. The  periosteum  is 
generally  thickened,  soft 
hypertrophic  medullary 
,  .  tissue,    containing     a    large 

Fig.  372. — Ihe  same  malacosteon  pelvis  seen  .  n      n   7      • 

from  the  outlet.  proportion   of    fat,    IS   depo- 

sited in  the  bones,  and  the 
calcareous  salts  are  absorbed.  They  are  believed  to  be  excreted 
through  the  kidneys. 

Microscopical  examination  shows  absorption  of  lime-salts  round 
the  Haversian  canals  and  the  canaliculi,  with  degenerative  changes 
in  the  animal  matrix  which  remains  ending  in  the  formation  of  a 
jelly-like  mass.  Numerous  small  haemorrhagic  exudations  are  to 
be  seen,  and  the  osteoclasts  are  increased  in  number. 

The  result  is  that  the  bones  become  very  light,  pliant,  soft,  and 
friable,  capable  of  being  easily  cut  or  indented.  In  some  forms  of 
the  disease  numerous  spontaneous  fractures  take  place.  The 
disease  sometimes  affects  the  whole  skeleton,  but  it  may  expend 
itself  chiefly  upon  certain  bones.  In  pregnant  women  the  spine, 
pelvis,  and  ribs  are  generally  most  affected. 

It  has  been  stated  that  there  is  an  excess  of  lactic  acid  in  the 
blood  leading  to  decalcification,  and  the  condition  has  been  called  a 
tropho-neurosis  and  has  been  supposed  to  be  dependent  upon  a 


Rare  Forms  of   Pelvic  Deformity.         765 


pathological  state  of  the  ovaries  with  an  altered  internal  secretion 
of  these  organs.  The  fact  that  the  disease  occurs  in  men  is  a 
strong  argument  against  any  such  hypothesis.  In  favour  of  this 
view,  however,  may  be  urged  the  good  results  and  the  frequent 
arrest  of  the  disease  which  follow  the  operation  of  ovariotomy. 

Mechanism  of  Production  of  the  Deformity. — The  reason  why  so 
different  a  state  is  produced  from  that  of  the  usual  rachitic  pelvis 
is,  first,  that  the  bones  are  softened  more  uniformly,  and  more 
completely,  so  that  they  can  no  longer  act  as  rigid  beams  or  levers  ; 
secondly,  that  the  woman  is  generally  standing  and  walking,  at 
least  in  the  early  stage  of  the  disease,  not  constantly  sitting,  like 
young  children  suffering  from  rickets.  In  the  early  stage  the  centre 
of  the  sacrum  sinks  some- 
what into  the  brim,  and  the  \ 
acetabula  are  driven  inward  y^^^'^^'iSk.Jii 
by  the  inward  pressure  of 
the  heads  of  the  femora, 
including  the  effects  of 
muscular  force  and  that  of 
pressure  in  lying  on  the 
side  (see  p.  28).  The 
bending  takes  place  most 
at  the  thinnest  parts  of  the 
bones  in  the  anterior  half 
of  the  pelvic  ring,  that  is  in 
the  superior  rami  of  the 
pubes,  and  near  the  junction 
of  pubes  and  ischium  (see 
Figs.  373,  374).      Thus,  the 

acetabula  come  to  look  more  forward  than  usual  (Fig.  374,  p.  766), 
the  pelvis  becomes  beaked,  and  the  shape  of  the  brim,  in  the  earlier 
stages,  is  a  pointed  heart-shape  (Fig.  373),  transverse  contraction 
predominating.  The  tubera  ischii  are  carried  inward  with  the 
acetabula,  so  contracting  the  outlet  (Fig.  374,  p.  766). 

The  effect  of  the  approximation  of  the  acetabula  is  that  the  out- 
ward leverage  upon  them,  due  to  the  reaction  of  the  body- weight  in 
standing  and  walking,  is  diminished,  and  eventually  converted  into 
an  inward  leverage,  if  the  acetabula  are  brought  nearer  to  the 
middle  line  than  the  sacro-iliac  joints  (see  p.  28).  The  same 
reaction  to  the  body-weight,  on  account  of  the  forward  direction  of 
tlie  acetabula,  comes  to  have  a  component  acting  inward  perpendi- 
cular to  the  pelvic  wall,  tending  more  and  more  to  bend  the  ilia,  as 
distortion  progresses.     The  reaction  to  the  body-weight  in  sitting, 


Fig.  373. — Rostrated   malacosteon   pelvis,   in 
earlier  stage  of  deformity. 


766 


The  Practice  of   Midwifery. 


action  on  the  tubera  iscbii,  also  comes  to  exercise  an  inward  instead 
of  an  outward  leverage,  as  soon  as  the  tubera  are  nearer  to  the 
middle  line  than  the  sacro-iliac  joints  (see  p.  28).  Hence  all  the 
forces  causing  distortion  act  at  constantly  increasing  advantage  as 
distortion  progresses.  Eventually  sacrum  and  acetabula  approach 
nearer  and  nearer  to  the  centre  of  the  pelvis,  as  do  the  tubera  ischii, 
and  the  space  both  of  inlet  and  outlet  is  almost  obliterated.  The 
sides  of  the  pubic  arch  are  closely  approximated.  The  crests  of  the 
ilia  are  folded  together  and  the  Dist.  Sp.  II.  diminished.  The 
acetabula,  and  with  them  the  ilio-pectineal  eminences,  are  also 
forced  upward  by  the  reaction  to  the  body-weight,  so  that  the 
anterior  and  posterior  halves  of  the  pelvic  ring  are  no  longer  in  the 

same  plane.  The  inclina- 
tion of  the  pelvis  as  a  whole 
is  also  diminished,  in  con- 
sequence of  the  displacement 
forward  of  the  sacrum  into 
the  brim,  for  the  same  reason 
as  in  the  rachitic  pelvis  (see 
p.  723).  In  extreme  forms 
of  distortion,  the  spine  often 
yields  irregularly,  producing 
corresponding  irregularity 
in  the  pelvis  (Figs.  371, 
372). 


Fig.  374. — Rostrated  malacosteon  pelvis,  seen 
from  the  outlet. 


The  Triradiate  Rachitic 
or  Pseudo  -  malacosteon 
Pelvis.  —  In  exceptional 
cases  of  rickets  a  form  of  pelvis  is  produced  closely  resembling 
the  malacosteon  pelvis  (Fig.  375,  p.  767).  For  its  production  it  is 
necessary  that  the  softening  of  the  bones  should  be  greater  and 
more  general  than  usual,  and  that  the  disease  should  be  pro- 
longed beyond  infancy,  so  that  the  child  walks  and  stands  while 
suffering  from  it.  If  the  child  walks  and  stands  while  the  softening 
is  only  slight,  the  result  is  the  rachitic  generally  contracted  pelvis 
(see  p.  714).  The  distinction  from  the  malacosteon  pelvis  is  made 
by  the  history,  by  the  signs  of  rickets  in  other  parts,  by  the  small 
size  of  the  pelvis,  especially  of  the  iliac  fossfe,  and  by  the  fact  that 
the  normal  relation  between  Dist.  Sp.  II.  and  Dist.  Cr.  II.  is 
reversed,  whereas  in  the  malacosteon  pelvis  the  spines  are  approxi- 
mated. In  other  words,  in  the  rachitic  form  the  iliac  fossfe  are 
flattened  and  look  forward,   in  the  malacosteon  they  are  folded 


Rare  Forms  of   Pelvic  Deformity.  767 

together  (Fig.  373,  p.  705).  In  the  rachitic  forra  also  the  bones 
are  not  so  pliable,  and  there  is  not  the  irregularity  often  seen  in 
extreme  degrees  of  osteo-malaeia. 

Diagnosis. — In  the  early  stages  of  osteo-malacia,  attention  may 
be  attracted  to  the  disease  by  the  occurrence  of  so-called  rheumatic 
pains  in  the  pelvis  and  other  bones,  together  with  some  paresis  of 
the  flexor  and  adductor  muscles  of  the  thighs.  The  next  change  is 
a  sensation  of  weakness  and  debility,  the  patient  is  unable  to  walk 
with  any  freedom,  while  the  gait  is  peculiar.  Bending  of  the  spine 
and  long  bones  occurs,  so  that  the  stature  is  apparently  shortened, 
and  ultimately  in  very  severe  cases  the  limbs  become  quite  flaccid 
and  useless.     When  the  deformity  is  established,  diagnosis  is  easily 


¥i(i.  375. — Pseiido-malacosteon  rachitic  pelvis,  viewed  in  the  axis  of  the  brim. 

(Naegele.) 

made,  in  the  slighter  forms  from  the  beaked  shape  of  the  pubes 
and  narrowing  of  the  pubic  arch,  in  severe  forms  from  the  great 
narrowing  of  the  outlet  and  cavity  of  the  pelvis  in  addition.  The 
bones  may  be  pliant  under  pressure,  and  there  may  be  deformities 
also  of  the  spine  and  other  bones.  The  rachitic  form  is  diagnosed 
by  the  characters  given  above,  and  by  the  bones  being  hard  and 
not  pliant. 

Treatment. — In  the  malacosteon  pelvis  trial  should  always  be 
made  whether  the  bones  may  not  prove  to  be  pliable  enough  to 
allow  the  pelvis  to  be  expanded  by  the  hand  passed  into  the 
vagina,  sufficiently  to  allow  extraction  of  the  foetus.  Failing  this, 
the  choice  will  generally  be  between  embryotomy  and  Cesarean 
section  (see  Chapter  XXIX.),  although  in  minor  degrees  of 
deformity  it  may  be  possible  to  extract  by  forceps.  Csesarean 
section  is  preferable  unless  labour  has  been  greatly  prolonged, 
since  the  ovaries  can  then  be  removed,  and  this  operation  has  been 
found  to  have  a  favourable  effect  upon  the  disease. 


768 


The  Practice  of   Midwifery. 


In  the  iDseudo-malacosteon  rachitic  pelvis,  with  an  equivalent 
degree  of  deformity,  it  is  still  more  likely  to  prove  impossible  to 


Malacosteon 


Naegele 

Fig.  376. — The  outline  of  the  pelvic  brim  in  the  principal  varieties  of 
contracted  pelvis.     (Bumm,  Grundris  der  Geburtshilfe.) 

extract  through  the  jDelvis,  since  the  pelvis  is  originally  smaller, 
and  the  bones  are  hard  and  not  pliant. 

The  Oblique  Pelvis. 

There  are  three  chief  forms    of   oblique   pelvis : — the   scoliotic 
oblique  pelvis,  due  to  lateral  curvature  of  the  spine ;  the  oblique 


Rare  Forms  of   Pelvic  Deformity.         769 

pelvis,  due  to  shortness  or  disuse  of  one  leg ;  and  the  oblique 
pelvis  of  Naegele,  due  to  deficiency  of  the  wing  of  the  sacrum 
and  anchylosis  of  the  corresponding  sacro-iliac  articulation, 
There  is  a  similar  action  of  certain  forces  in  the  production  of 
all  these. 

The  Scoliotic  Oblique  Pelvis. — In  lateral  curvature  (scoliosis) 
of  the  spine,  the  bodies  of  the  vertebrae  are  rotated  to  one  side  in 
the  dorsal  region,  to  the  opposite  side  in  the  lumbar  region. 
Generally  the  deviation  is  to  the  right  in  the  dorsal  region,  being 
due  to  the  over-use  of  the  right  arm,  and  to  the  left  in  the  lumbar 
region.  The  result  is  that  the  line  by  which  the  body-weight  is 
transmitted  to  the  pelvis  is  displaced  to  the  same  side  as  the 
bodies  of  the  vertebrae,  and  one  leg  or  tuber  ischii  has  to  bear 
more  than  its  share  of  the  weight.  The  bones  and  muscles  of  the 
overweighted  leg  often  become  thicker.  Hence  the  inward  thrust 
at  the  acetabulum,  due  to  muscular  action,  is  greater  than  on  the 
other  side,  and  this  is  one  cause  why  the  acetabulum  is  pushed 
inward,  and  the  symphysis  pubis  is  displaced  toward  the  opposite 
side  (Fig.  377,  p.  770). 

Another  cause  is  the  following.  When  the  line  of  body-weight 
is  displaced  much  to  one  side,  it  cuts  the  posterior  sacro-iliac 
ligament  on  one  side  (see  Fig.  15,  p.  13)  instead  of  falling  in  the 
middle  line  between  the  two  ligaments.  A  consideration  of  the 
equilibrium  of  the  sacral  beam  itself  shows  that  the  result  must 
be  that  more  and  more  strain  is  thrown  upon  those  fibres  of  the 
ligament  close  to  the  joint,  and  upon  the  "  bite "  on  the  bony 
surface  which  exists  in  the  Joint  itself,  and  is  pressed  more  strongly 
than  usual  against  the  ilium.  Otherwise  the  over-weighted  end 
of  the  sacrum  would  be  displaced  downward,  away  from  the 
corresponding  ilium.  It  follows  that,  although  the  weight  trans- 
mitted to  the  ilium  on  the  over-weighted  side  is  increased,  the 
posterior  arm  of  the  lever  formed  by  the  innominate  bone  is 
diminished  in  more  than  the  same  proportion.  The  leverage, 
therefore,  is  diminished  on  the  over- weighted  side,  and  that  on  the 
other  side  preponderates  over  it,  and  displaces  the  symphysis 
pubis  toward  the  under-weighted  side. 

As  soon  as  displacement  of  the  acetabulum  inward  has  begun, 
the  princij^le  already  mentioned,  by  which  the  tendency  to  dis- 
placement is  thereby  increased,  comes  into  play  (see  p.  699),  for 
the  outward  leverage  of  the  reaction  to  body-weight  at  the 
aceiabalum  is  diminished,  and  may  be  eventually  converted  into 
inward  leverage,  as  in  the  triradiate  pelvis,  if  one  acetabulum  is 

M.  49 


770 


The  Practice  of   Midwifery. 


brought  nearer  than  the  corresponding  sacro-iliac  jomt  to  the 
middle  line. 

The  other  chief  changes  produced  in  consequence  of  the  obliquity 
are  the  following.  The  wing  of  the  sacrum  and  the  ilium  on  the 
over-weighted  side  are  thickened  and  shortened  from  the  effect  of 
extra  pressure  acting  in  the  axis  of  the  bone.  The  pelvic  brim  is 
elevated  on  the  over-weighted  side,  there  is  some  bulging  inward 
opposite  the  acetabulum,  the  crest  of  the  ilium  is  higher,  the  iliac 
fossa. looks  more  inward. 

Generally  there  is  in  addition  some  flattening  in  the  scoliotic 
pelvis.  This  may  be  due  simply  to  increased  pelvic  inclination  in 
consequence  of  the  normal  antero-posterior  curves  of  the  spine 


Fig.  377. — Scoliotic  flattened  pelvis.     (After  A.  Martin.) 

being  exaggerated,  or  it  may  be  the  result  of  associated  rickets, 
The  characters  of  the  flattened  pelvis,  rachitic  or  otherwise,  are 
therefore  generally  more  or  less  combined  with  those  mentioned 
above  (see  Fig.  377). 


The  Oblique  Pelvis  from  Shortening  or  Disease  of  one 
Leg. — This  is  closely  allied  to  the  last  form.  Unless  the  legs  are 
equalised  by  the  wearing  of  a  high  boot,  the  pelvis  is  tilted  down- 
ward on  the  side  of  the  shortening.  This  displaces  the  line  of  the 
body-weight  toward  that  side,  and  the  shortened  leg  becomes 
over-weighted.  Obliquity  of  the  pelvis  is  produced  by  the  same 
forces  as  in  the  former  case.  There  is  here  also  an  additional 
cause,  namely,  that  from  the  tilting  of  the  pelvis  the  reaction  to 
the  body-weight  at  the  acetabulum  on  the  side  of  the  shortened  leg 


Rare  Forms  of  Pelvic  Deformity.         771 

is  inclined  inward  toward  the  centre  of  the  pelvis  (which  normally- 
it  is  not),  and  therefore  has  a  component  producing  an  inward 
thrust.  The  scoliosis  of  the  spine,  secondary  to  the  tilting  of  the 
pelvis,  will  still  further  increase  the  effect. 

A  similar  effect  is  produced  when  the  function  of  one  leg  is 
destroyed,  as  by  amputation,  disease  of  hip-joint  or  other  parts, 
fracture,  or  unreduced  dislocation,  and  the  patient  stands  and 
walks  with  the  remaining  leg  and  a  crutch.  The  effects  of  over- 
weight are  then  manifested  on  the  side  of  the  sound  leg,  and 
the  symphysis  pubis  is  displaced  toward  the  opposite  side.  In 
Fig.  378  is  shown  an  oblique  pelvis  due  to  the  disease  and 
anchylosis  of  one  hip-joint.  The 
atrophy  of  the  pelvic  bones,  pubes 
and  ischium,  on  the  side  which 
bears  no  weight,  is  in  this  -  case 
very  marked. 

The  Oblique  Pelvis  of 
Naegele. — The  essential  charac- 
ters of  this  pelvis  are  that  there  is 
complete  absence  or  imperfect 
development  of  one  wing  of  the 
sacrum  and  anchylosis  of  the  cor- 
responding sacro-iliac  joint,  caus- 
ing bony  union  between  the 
sacrum  and  innominate  bone.  It 
is  probable  that  the  maldevelop-  fig.  378.— Oblique  pelvis,  from  Zichj- 
ment  is  primary  and  the  anchy-  ^osis  of  the  hip-joint,  and  disuse  of 

right  leg 

losis  is  secondary,  since  the  whole 

of  the  ala  may  be  absent  without  any  bony  union,  and  pelves  have 

been  described  in  which  one  or  more  of  the  alse  of  separate  sacral 

vertebras  have  been  absent  while  the  remainder  were  present  and 

normal. 

The  condition  may,  however,  be  due  to  disease  of  the  joint 
in  early  infancy,  or  to  caries  affecting  its  neighbourhood;  and 
if  this  occurs  at  a  very  early  age  the  ultimate  effect  upon  the 
pelvis  is  the  same  as  that  produced  by  the  congenital  mal- 
development. 

Naegele,  however,  himself  considered  that  the  deformity  is  the 
result  of  an  original  anomaly  of  development,  because  there  is 
generally  no  history  of  disease,  nor  evidence  of  it  in  the  appear- 
ance of  the  bones,  and  because  the  bony  fusion  is  complete.  In 
the  case  of  anchylosis  of  the  joint  produced  by  inflammation  later 

49—2 


772 


The  Practice  of   Midwifery. 


in  childhood,  a  less  complete  form  of  the  Naegele  obliquity  may 
result  1  (Fig.  380,  p.  773). 

Causation.— The  deformity  is  produced  in  the  following  way. 
Complete  bony  union  forms  between  the  sacrum  and  the  ilium  at  a 
very  early  period,  and  the  wing  of  the  sacrum  remains  quite 
undeveloped.  The  growth  of  the  ilium  is  not  affected  because  the 
synostosis  does  not  affect  its  growing  extremities.  The  leverage  of 
the  innominate  bone  on  the  affected  side  is  entirely  destroyed,  and 
the  weight  of  the  body  on  that  side  is  transmitted  through  the  bony 
union.  Hence,  since  the  ilium  is  not  subjected  to  the  usual  bend- 
ing force,  its  inner  border  on  the  affected  side,  which  forms  a  part 
of  the  ilio-pectineal  line,  remains  almost  absolutely  straight  (see 


Fig.  379. — Oblique  pelvis  of  Naegele. 


Fig.  379),  instead  of  becoming  more  sharply  curved  than  usual,  as 
in  the  other  forms  of  oblique  pelvis  (Fig.  377,  p.  770,  and  Fig.  378, 
p.  771).  This  peculiarity  is  perhaps  the  most  striking  proof  of  the 
truth  of  the  theory  as  to  the  leverage  action  of  the  innominate  bone. 
The  obliquity  of  the  pelvis  results  from  two  causes  :  first,  the 
deficiency  of  the  sacral  wing ;  secondly,  the  anchylosis.  The  first 
calls  out  forces  similar  to  those  which  act  in  the  two  other  forms  of 
oblique  pelvis.  The  line  of  body-weight  falls  nearer  to  the 
acetabulum  and  tuber  ischii  on  the  affected  side.  Hence  the  leg 
on  that  side  is  over- weighted,  the  muscles  hypertrophied  in  com- 
parison with  those  on  the  other  side,  and  the  inward  pressure  at 
the  acetabulum,  due  to  muscular  action,  is  increased. 

In  consequence  of  the  anchylosis,  the  leverage  exerted  by  the 

1  See  Champneys,  "  On  the  Obliquely  Contracted  Pelvis  of  a  Child  with  Left  Sacro- 
liac  Synostosis,"  Trans.  Obst.  Soc.  London,  1882,  Vol.  XXIV.,  p.  191. 


Rare  Forms  of   Pelvic  Deformity.  773 

posterior  sacro-iliac  ligaments  on  the  innominate  bone  on  the 
sound  side  (see  Fig.  25,  p.  27),  being  unopposed,  draws  over  the 
symphysis  pubis  toward  the  sound  side,  and  thus  forms  an  additional 
force  causing  obliquity.  It  is  difficult  to  say  which  of  the  two 
causes  has  the  greatest  influence  in  causing  the  oblique  shape. 
Probably  the  deficiency  of  the  sacral  wing  has  most,  since  an 
obliquity  as  great  as  that  of  the  Naegele  pelvis  may  result  without 
any  unilateral  action  of  the  leverage  of  the  posterior  sacro-iliac 
ligaments  (see  Fig.  378,  p.  771).  But  the  effect  of  the  unilateral 
leverage  is  shown  in  the  straightness  of  the  ilio-pectineal  line  near 
the  anchylosed  joint,  as  already  mentioned. 

The  more  obliquity  has  been  already  j)roduced  by  the  action  of 
these  two  causes,  the  more  the  forces  tend  to  increase  the  obliquity. 


Fig.  380. — An  oblique  pelvis  of  Naegele,  in  which  the  distortion 
is  only  slight. 

according  to  the  principle  which  has  been  already  explained  (see 
pp.  698,  699). 

Other  resulting  changes  in  the  pelvis  are  that  the  affected  side 
is  elevated,  the  ilium  is  shortened  and  thickened  from  excessive 
pressure  in  the  axis  of  the  bone,  the  crest  is  elevated  and  the  iliac 
fossa  looks  more  inward.  The  last  peculiarity  is  more  marked, 
being  partially  due  to  failure  of  leverage  acting  on  the  ilium. 
Owing  to  the  synostosis  on  one  side,  that  sinking  forward  of  the 
sacrum  between  the  ilia,  which  normally  takes  place  in  the  advance 
from  infancy  to  adult  life,  can  only  occur  on  the  sound  side.  Thus 
is  produced  a  turning  of  the  anterior  face  of  the  sacrum  toward 
the  affected  side,  not  only  in  reference  to  the  distorted  pelvis,  but 
in  reference  to  the  mesial  plane  of  the  body.  The  pubic  arch  is 
narrowed,  from  one  tuber  ischii  being  inverted,  and  faces  somewhat 
toward  the  deformed  side  (see  Fig.  379). 

There  is  an  important  difference  as  regards  the  tuber  ischii  from 


774 


The  Practice  of   Midwifery. 


other  forms  of  oblique  pelvis.  In  the  scoliotic  pelvis  (see  Fig.  377, 
p.  770)  this  is  everted  in  the  usual  way  from  the  reaction  to  the 
body- weight  acting  on  the  tuber  ischii  in  sitting  (see  p.  30), 
especially  since  the  pelvis  generally  partakes  of  the  flattened 
character,  and  this  side  has  to  bear  more  than  its  share  of  the 
weight.  In  Naegele's  oblique  pelvis,  on  the  contrary,  owing  to  the 
absence  of  the  sacral  wing,  and  the  straightness  of  the  innominate 
bone,  the  tuber  ischii  initially  falls  very  little  outside  the  line 
joining  the  junctions  of  the  innominate  bone  with  the  sacrum  and 


Fig.  381. — Oblique  pelvis  of  Naegele  seen  from  behind.     (Naegele,  Das 
Schrag  Yerengte  Becken.,  Fig.  Y.) 


pubes.  The  tendency  to  rotate  the  lower  part  of  the  innominate 
bone  outward  on  an  axis  passing  through  these  junctions  is  therefore 
much  diminished,  and  the  tuber  ischii,  which  is  always  drawn 
inward  by  the  tension  of  the  great  sacro-sciatic  ligament,  remains 
inverted,  as  compared  with  that  on  the  opposite  side,  and  so  con- 
tracts the  pelvic  outlet  (Fig.  381).  The  same  counter-pressure 
on  the  tuber  ischii,  since  the  tuber  is  often  nearer  the  middle 
line  than  the  synostosis  of  sacrum  and  ilium,  tends  also  to  rotate 
the  anterior  end  of  the  innominate  bone  inward  on  an  axis  perpen- 
dicular to  the  brim  through  that  synostosis.  The  former  of  those 
two  effects  depends  upon  the  component  of  the  counter-pressure 
resolved  perpendicularly  to  the  plane^of  the  brim,  the  latter  upon 


Rare  Forms  of   Pelvic  Deformity.  775 

the  component  resolved  in  a  direction  parallel  to  the  same  plane, 
as  explained  at  pp.  26 — 33.  Thus  the  effect  of  sitting,  as  well  as 
standing,  tends  to  increase  the  obliquity. 

In  all  the  forms  of  oblique  pelvis,  the  ilio-pectineal  line  on  the 
under-weighted  or  less  contracted  side  has  its  curvature  diminished 
at  the  posterior  part,  and  increased  at  the  anterior  part.  Not  only 
is  the  ilium  on  the  over-weighted  side  shortened  and  thickened  by 
excessive  pressure  in  its  axis,  but  the  same  effect  is  produced  also 
on  the  superior  ramus  of  the  pubes  which  forms  the  opposite 
quadrant  of  the  pelvic  brim,  for,  being  parallel  to  the  oblique 
diameter  which  is  undergoing  compression,  this  is  also  subject  to 
extra  pressure  in  its  axis. 

In  all  forms  of  oblique  pelvis,  one  oblique  diameter  of  the  brim 
is  shortened  and  the  other,  if  anything,  lengthened.  Also  the 
greatest  shortening  affects  the  sacro-cotyloid  diameter  on  the  over- 
weighted side.  The  shortening  and  the  general  contraction  are 
much  the  greatest  in  Naegele's  pelvis,  on  account  of  the  absence  of 
the  sacral  wing  and  the  contraction  of  the  outlet.  A  pelvis  approxi- 
mating in  shape  to  Naegele's  pelvis  may  be  produced  if,  without 
any  anchylosis,  but  in  consequence  of  caries,  disease  of  the  joint, 
or  any  other  cause,  one  wing  of  the  sacrum  is  less  developed  than 
the  other. 

Diagnosis. — Scoliosis  of  the  spine  or  an  affection  of  one  leg  will 
attract  attention  to  the  probable  pelvic  obliquity.  A  Naegele's 
pelvis  may  easily  be  overlooked  unless  special  examination  is  made. 
A  difference  in  the  distance  from  the  last  lumbar  vertebra  to  the 
posterior  superior  iliac  spine,  and  from  the  tip  of  the  sacrum  to  the 
tuber  ischii  on  the  two  sides,  is  the  best  sign  of  deficiency  of  one 
wing  of  the  sacrum.  If  the  woman  is  made  to  stand  upright  and 
a  plumb-line  is  let  fall  from  a  sacral  spine,  and  another  from  the 
symphysis  pubis,  a  line  joining  the  two  will  deviate  from  the  mesial 
plane  in  an  oblique  pelvis.  The  best  test  is,  however,  vaginal 
examination.  If  the  promontory  of  the  sacrum  is  reached,  it  will 
be  found  to  deviate  to  one  side,  and  the  diminished  lateral  space 
on  that  side  will  be  detected.  Certain  external  oblique  or  diagonal 
measurements  may  be  compared  on  the  two  sides,  but  too  much 
reliance  should  not  be  placed  upon  this  comparison.  The  following 
characters  are  given  by  Naegele  for  the  Naegele  pelvis : — 

(1)  The  distance  from  the  tuber  ischii  of  the  deformed  side  to  the 
posterior  superior  spine  of  the  opposite  ilium  is  shorter  than  its 
fellow. 

(2)  The  distance  from  the  anterior  superior  spine  of  the  deformed 
side  to  the  opposite  posterior  superior  spine  is  shorter  than  its  fellow. 


776  The  Practice  of   Midwifery. 

(3)  The  distance  from  the  spinous  process  of  the  last  lumbar 
vertebra  to  the  anterior  superior  spinous  process  of  the  deformed 
side  is  shorter  than  its  fellow. 

(4)  The  distance  from  the  great  trochanter  on  the  deformed 
side  to  the  opposite  posterior  superior  spine  is  shorter  than  its 
fellow. 

(5)  The  distance  from  the  symphysis  pubis  to  the  posterior 
superior  spine  on  the  deformed  side  is  longer  than  its  fellow. 

In  all  these,  except  No.  3,  that  is  to  say,  in  all  the  diagonal 
measurements,  it  will  be  seen  that  the  posterior  extremity  of  that 
measurement  which  exceeds  its  fellow  is  on  the  side  of  the 
anchylosis. 

Mechanism  of  Labour. — The  mode  in  which  the  head  enters 
the  brim  varies  according  to  the  exact  size  and  shape  of  the  pelvis. 
If  the  deformity  is  slight,  the  long  diameter  of  the  head  enters  in 
the  longer  oblique  diameter.  If  one  sacro-cotyloid  diameter  is 
greatly  contracted,  the  corner  of  the  brim  which  it  shuts  off  cannot 
be  utilised  by  the  head  at  all.  The  long  diameter  then  enters  in 
a  diameter  approximating  to  the  shorter  oblique  (see  Fig.  377, 
p.  770,  and  Fig.  380,  p.  773),  but  having  its  anterior  end  nearer  to 
the  symphysis  pubis. 

Prognosis. — Naegele's  oblique  pelvis  causes  great  difficulty  in 
delivery.  According  to  Litzmann's  statistics,  out  of  28  mothers 
22  died  after  the  first  confinement,  3  after  the  second,  and  2  after 
the  sixth.  Only  6  of  41  labours  ended  spontaneously ;  of  the 
remainder  2  were  delivered  by  Cesarean  section,  4  by  premature 
labour,  13  after  perforation  of  the  child's  head,  and  the  remainder 
by  the  use  of  forceps  or  manual  extraction.  Five  women  died 
undelivered.  Of  the  41  children  10  only  were  born  alive,  and  of 
these  4  were  by  the  same  mother.  The  scoliotic  pelvis,  when  com- 
bined with  the  rachitic  type,  may  also  cause  great  difficulty.  While 
Naegele's  oblique  pelvis  is  very  rare,  slight  degrees  of  obliquity,  in 
combination  with  flattening  of  the  pelvis,  are  relatively  common. 

Treatment — In  the  first  two  forms  of  oblique  pelvis,  if  the 
distortion  is  moderate,  forceps  may  be  tried,  and,  if  they  fail, 
craniotomy  performed.  It  is  not  desirable,  as  a  rule,  to  perform 
version,  unless  the  flattening  of  the  pelvis  preponderates  over  its 
obliquity.  But  if  the  long  diameter  of  the  head  does  not  appear 
to  lie  in  the  best  available  diameter  of  the  pelvis,  version  may  be 
performed,  the  leg  brought  down  being  so  chosen  as  to  bring  the 
head  into  the  opposite  oblique  diameter,  but  it  must  be  remembered 
that,  in  considerable  obliquity,  the  longer  oblique  diameter  of  the 
pelvis  does  not  give  most  room  for  the  head.     If  the  head  cannot 


Rare  Forms  of   Pelvic  Deformity.         777 

be  brought  through,  perforation  of  the  after-coming  head  must  be 
performed. 

In  the  oblique  pelvis  of  Naegele  the  difficulty  is  likely  to  be 
greater  at  the  brim  and  still  more  at  the  outlet.  Cesarean  section 
is  generally  preferable  as  a  first  choice,  otherwise  craniotomy  will 
usually  be  required. 

Ischiopuhiotomy. — Prof.  Pinard,  of  Paris,  successfully  performed 
the  operation  of  ischiopuhiotomy  in  an  oblique  pelvis  of  Naegele. 
The  two  rami  of  the  pelvis  are  sawn  through  on  the  diseased  side 
between  pubes  and  ischium,  and  between  pubes  and  ilium.  The 
symphysis  pubis  is  thus  allowed  to  rotate  outward  upon  the  sacro- 
iliac joint  of  the  sound  side,  as  the  two  pubic  bones  do  in  symphy- 
siotomy.    The  gap  thus  obtained  is  supposed  to  be  better  placed  for 


Fig.  382. — Transversely  contracted  pelvis  of  Robert. 

allowing  the  head  to  pass  than  if  it  were  at  the  symphysis  pubis. 
This  operation  should  only  be  considered  if  it  is  desired  to  save 
the  child  after  prolonged  labour  or  attempts  to  extract  through  the 
pelvis. 

Transversely  Contracted  Pelvis, 

There  are  two  most  marked  forms  of  the  transversely  con- 
tracted pelvis,  namely,  the  transversely  contracted  pelvis  of  Kobert 
(Fig.  382),  due  to  anchylosis  of  both  sacro-iliac  joints,  and  the 
kyphotic  pelvis  (Fig.  384,  p.  780). 

Transversely   Contracted   Pelvis   of  Robert The  mode    of 

formation  of  this  deformity  has  to  be  considered  in  close  connection 
with  the  obliquely  contracted  pelvis  of  Naegele.     The  difference 


778  The  Practice  of   Midwifery. 

is  that,  in  Eobert's  pelvis  the  anchylosis  affects  both  sacro-iliac 
articulations,  and  development  of  both  wings  of  the  sacrum  fails. 
In  this,  as  in  the  Naegele  oblique  pelvis,  there  are  two  possible 
explanations  of  the  production  of  the  deformity,  the  first  that 
there  is  a  primary  maldevelopment  of  the  alfe  of  the  sacrum, 
associated  or  not,  as  the  case  may  be,  with  secondary  anchylosis 
of  the  two  sacro-iliac  articulations,  and  the  second  that  the  synos- 
tosis of  the  joints  is  the  primary  condition  and  has  as  a  result  the 
maldevelopment  of  the  alse.  Breus  and  Kolisko  maintain  that 
the  latter  is  the  true  explanation.  As  both  al?e  are  involved, 
there  is  no  inequality  from  unilateral  action,  but  the  other 
effects  of  the  failure  of  the  action  of  leverage  on  the  ilia,  and  the 
want  of  the  transverse  width  given  to  the  pelvis  by  the  sacrum, 
are  apparent.  Not  only  does  the  widening  of  the  pelvis  usually 
caused  by  the  leverage  exercised  by  the  posterior  sacro-iliac  liga- 
ments fail,  but  the  outward  leverages  at  the  acetabula,  due  to  the 
reactions  to  the  body-weight  (see  p.  28),  are  diminished,  the 
acetabula  being  nearer  to  the  middle  than  usual.  On  both  sides 
the  inner  border  of  the  ilium  which  forms  part  of  the  ilio-pectineal 
line  is  nearly  straight,  and  thus  the  transverse  narrowing,  due  to 
the  want  of  the  alae  of  the  sacrum,  is  increased.  Both  tubera  ischii 
are  inverted,  instead  of  one,  as  in  Naegele's  oblique  pelvis,  and 
hence  the  outlet  is  contracted  even  more  than  the  inlet  (see  p.  699) , 
the  pubic  arch  is  very  acute,  and  the  pelvis  somewhat  funnel- 
shaped.  The  distance  between  the  tubera  ischii  may  not  be  more 
than  two  inches.  The  antero-posterior  diame-ter  of  the  brim  is 
about  normal,  the  transverse  much  contracted.  The  iliac  fossse 
are  more  upright  than  usual,  but  flat  and  directed  anteriorly.  In 
described  pelves  of  this  kind  the  sacrum  has  been  deeply  sunk 
between  the  ilia,  and  the  concavity,  in  transverse  section,  of  the 
anterior  surface  converted  into  a  convexity.  This  does  not  seem 
explained  by  the  mode  of  production  of  the  deformity,  but  may  have 
been  due  to  a  softening  of  the  sacrum  by  the  diseased  condition 
of  the  bone  which  produced  the  double  anchylosis,  or  else  to  an 
exaggerated  pelvic  inclination. 

Eobert's  pelvis  is  extremely  rare,  and  only  about  thirteen  well- 
marked  pelves  of  this  kind  have  been  described.  The  difficulty  in 
delivery  which  it  causes  is,  as  might  be  expected,  much  greater  than 
even  in  Naegele's  oblique  pelvis.  Of  eight  recorded  cases,  the 
women  were  delivered  in  six  by  Cesarean  section.  In  two  they  were 
delivered  by  craniotomy,  but  died  after  parturition.^ 

1  Spiegelberg,  Lehrbuch  der  Geburtshiilfe,  English  translation,  Hurry,  Vol.  II., 
p.  107. 


Rare  Forms  of   Pelvic  Deformity.         779 


The  diagnosis  would  be  made  easily  by  the  great  contraction  of 
the  outlet,  and  the  smallness  of  the  transverse  diameters  (Dist.  Sp. 
II.  and  Dist.  Cr.  II.). 

I  have  met  with  one  instance  in  which  a  similar  transverse 
contraction  of  the  pelvis  was  ]3roduced 
apparently  not  so  much  by  absence  of 
the  wings  of  the  sacrum  as  by  extreme 
stunting  in  development  of  the  whole 
bone,  which  was  less  than  half  its 
normal  length  as  well  as  very  narrow, 
while  the  antero-posterior  diameter  of 
the  pelvis  was  normal.  The  trans- 
verse diameter  of  the  outlet  between 
the  tubera  ischii  was  less  than  two 
inches.  The  shortness  of  the  sacrum, 
however,  allowed  more  space  than 
usual  behind  the  tubera.  Delivery 
was  effected  by  the  cephalotribe  after 
craniotomy,  without  very  great  diffi- 
culty, entirely  through  the  posterior 
half  of  the  pelvic  outlet,  and  the 
patient  did  well. 

Treatment. — Csesarean  section  is  best 
as  a  primary  choice.  It  may  be  pos- 
sible when  Caesarean  section  is  contra- 
indicated  to  extract  after  perforation  by 
the  cephalotribe,  the  blades  being  kept 
exactly  lateral,  if  the  outlet  allows 
sufficient  space  to  apply  it. 


Fig.  383.— Figure  of  pregnant 
woman  with  kyphotic  pelvis. 
Pelvic  measurements :  Dist. 
Sp.  II.,  9  ins.  ;  Dist.  Cr.  II., 
9  ins.  ;  Ext.  Con j . ,  6f  ins. ; 
Diag.  Conj.,  4i  ins.  ;  Dist, 
Tub.  Isch.,  31  ins.  First 
pregnancy,  labour  induced 
at  thirty-fourth  week,  child 
delivered  by  version  and  per- 
foration of  after-coming  head, 
which  was  obstructed  at  out- 
let of  pelvis.  Second  preg- 
nancy, labour  induced  at 
thirty-fourth  week,  and  living 
child  delivered. 


The  Kyphotic  Pelvis.  — The 
kyphotic  pelvis  is  a  form  of  transversely 
contracted  pelvis  resulting  from 
kyphosis  (curvature  with  the  concavity 
forward)  of  the  lumbar  vertebrae  with 
the  sacrum  (Fig.  384).  This  is  gener- 
ally the  consequence  of  caries  in  that 

situation  leading  to  a  falling  together  and  fusing  of  the  bodies  of 
the  vertebrse.  Frequently,  there  is  a  compensatory  lordosis 
(curvature  with  the  convexity  forward)  in  the  dorsal  region.  When 
this  is  the  case  the  natural  curves  of  the  dorsal  and  lumbar  region 
are  exactly  reversed.  If  the  kyphosis  affects  the  dorsal  region,  as  a 
rule  it  produces  but  little  effect  upon  the  pelvis.    When,  however,  it 


78o 


The  Practice  of   Midwifery. 


is  in  the  lumbar  region,  and  more  especially  when  it  involves  the 
upper  end  of  the  sacrum,  the  pelvis  is  markedly  affected.  In  some 
cases  the  superior  strait  of  the  pelvis  is  so  overhung  by  the  vertebral 
column  as  to  produce  the  so-called  pelvis  obtecta.  If  not,  the 
plane  of  the  pelvic  brim  is  almost  perpendicular  to  the  general  axis 
of  the  spine,  as  may  be  seen  in  Fig.  384.  Hence,  in  order  to 
preserve  the  balance  of  the  body  in  standing  or  sitting,  the  pelvic  brim 
must  be  almost  horizontal  instead  of  being  inclined  to  the  horizon 
at  an  angle  of  55°  or  60°.  Even  when  the  kyphosis  is  somewhat 
compensated  by  a  lordosis  above,  the  pelvic  inclination  must  be 
greatly  diminished.  The  vertical  space  in  the  abdomen  is  much 
diminished,  the  ribs  being  approximated  to  the  iliac  crests,  with 


Fig.  3Si. — Kyphotic  pelvis. 

the  result  that  the  abdomen  tends  to  become  markedly  pendulous, 
and  abnormal  presentations  are  especially  frequent.  The  resulting 
figure  is  shown  in  Fig.  383. 

Mechanism  of  Production  of  the  Deformity. — All  the  peculi- 
arities of  the  kyphotic  pelvis  are  explained  by  the  abolition  or 
diminution  of  the  pelvic  inclination.  The  weight  of  the  body, 
instead  of  tending  to  force  the  sacrum  downward  into  the  brim, 
tends  only  to  force  it  in  the  direction  of  the  coccyx.  Thus  the 
action  of  the  leverage  of  the  innominate  bone  in  widening  the 
pelvis  is  almost  or  entirely  abolished,  and  the  inward  thrust  at 
the  acetabula  due  to  muscular  action  is  unopposed.  Hence  the 
pelvis  is  flattened  transversely  and  elongated  antero-posteriorly, 
like  a  monkey's  pelvis  (see  Fig.  10,  p.  7).  Narrowness  already 
existing  to  some  extent,  the  effect  of  sitting  in  everting  the  tubera 
ischii  (see  p.  30)  is  diminished  or  even  reversed,  while  that  of  the 


Rare  Forms  of   Pelvic  Deformity.         781 

tension  of  the  great  sacro-sciatic  ligaments  in  inverting  them  is 
increased  in  consequence  of  the  antero-posterior  lengthening  of 
the  pelvis.  The  tubera  and  spines  of  the  ischium  are  thus 
approximated  and  the  pubic  arch  narrowed. 

In  standing,  the  weight  of  the  body  is  transmitted  to  the  pelvis 
much  further  back  than  usual  in  reference  to  the  vertical  plane 
through  the  heads  of  the  femora.  As  a  result  of  the  destruction  of 
some  of  the  bodies  of  the  vertebrae  by  caries,  the  bod3'-weight  tends 
to  be  transmitted  through  the  arches  and  the  transverse  processes ; 
this  results,  when  the  kyphosis  is  sufficiently  high  up,  in  a  marked 
lordosis  of  the  spine  below  it,  and  in  elongation  of  the  bodies  of  the 
sacral  vertebrge.^ 

The  body  can  only  be  balanced  on  the  heads  of  the  femora  by  a 
general  inclination  of  the  spine  forward,  a  position  calling  for  more 
muscular  effort  to  maintain  than  the  normal  position  of  the  spine, 
namely,  one  coinciding  on  the  whole  with  a  vertical  line,  the  curve 
falling  alternately  in  front  and  behind.  To  avoid  this  muscular 
effort,  in  the  position  of  "  standing  at  ease,"  more  strain  than  usual 
is  thrown  upon  the  ilio-femoral  ligaments,  attached  to  the  anterior 
inferior  spine  of  the  ilium  and  the  upper  border  of  the  acetabulum, 
and  the  spine  is  thus  rendered  more  erect.^ 

The  result  of  the  over-action  of  the  ligaments  is  shown  by 
increased  bony  prominences  in  these  situations  (see  Fig.  384). 
The  effect  of  this  increased  tension  tends  to  rotate  the  innominate 
bone  on  an  axis  passing  through  the  sacro-iliac  joint  and  symphysis 
pubis,  inverting  still  more  the  lower  part  of  the  innominate  bone, 
the  tuber  and  spine  of  the  ischium,  and  everting  the  upper  part 
with  the  iliac  fossae.  As  regards  the  sacrum  itself,  the  results  of 
the  altered  direction  of  the  body-weight  are  that  the  transverse 
concavity  is  greater  than  in  the  normal  adult  pelvis,  the  antero- 
posterior concavity  less.  The  promontory  is  not  rotated  forward, 
but  rather  the  lower  extremity,  partly  from  the  traction  of  the 
sacro-sciatic  ligaments,  partly  from  the  falling  together  of  the 
bodies  of  the  vertebrae.  The  iliac  fossae  are  everted,  looking  upward 
and  forward,  and  the  S-shaped  curve  of  the  crest  is  slight.  This 
result,  like  the  inversion  of  the  tuber  and  spine  of  the  ischium, 
follows  from  the  altered  effect  of  sitting,  and  the  traction  of  the  ilio- 
femoral ligaments.  In  some  cases  the  sacrum  is  very  narrow,  a 
result  probably  due  to  the  disease  which  led  to  the  kyphosis. 

1  Breus  and  Kfjlisku,  \)\(:  I'lithologischen  Beckenformcn,  1900,  p.  163. 

2  it  is  not  sufficient  merely  to  say  that  the  rotation  of  the  pelvis  backward,  to  bring 
about  the  diminished  inclination,  (tuts  these  ligaments  on  the  stretch.  If  this  were 
all,  the  ligaments  would  doiihlless  accommodate  themselves  to  the  position  of  the 
pelvis. 


782  The  Practice  of   Midwifery. 

The  final  result  is  that  at  the  brim  there  is  alteration  of  shape 
but  no  contraction  of  importance,  while  at  the  outlet  contraction 
may  be  very  considerable.  Unless  the  sacrum  is  narrowed,  the 
brim  is  actually  larger  than  normal,  from  the  eversion  of  the  upper 
part  of  the  innominate  bones.  In  some  cases,  however,  the  dimen- 
sions of  the  brim  are  in  reality  smaller  than  normal  owing  to  the 
presence  of  some  general  contraction. 

Mechanism  of  Labour. — It  might  be  expected  that  the  long 
diameter  of  the  head  would  enter  the  long  diameter  of  the  brim, 
and  it  doubtless  does  so,  when  it  fits  the  brim  at  all  tightly,  a  result 
which  can  only  hapj)en  when  there  is  a  considerable  narrowing  of 
sacrum  or  general  contraction,  in  addition  to  the  kyphosis.  But 
it  is  most  frequently  found  that  the  long  diameter  enters  obliquely 
or  even  transversely,  since  it  finds  room  to  pass  easily  even  the 
smaller  transverse  diameter,  and  its  direction  is  therefore  deter- 
mined by  that  of  the  foetus  in  utero..  According  to  Klien,^  in 
37  to  38  per  cent,  of  all  head  presentations  the  occiput  is 
directed  backwards,  a  result  no  doubt  of  the  condition  of  pendulous 
abdomen  so  often  seen  with  these  pelves,  and  the  absence  of  the 
normal  lumbar  convexity  of  the  spine.  For  the  spine  of  the  child 
will  not  be  near  enough  to  the  spine  of  the  mother  to  be  repelled 
by  it  and  turned  forwards.  Brow  and  face  presentations  are  also 
relatively  frequent  in  kyphotic  pelves.  The  difficulty  generally 
begins  when  the  head  approaches  the  outlet.  Here  the  head  is 
often  unable  to  use  the  anterior  part  of  the  space,  on  account 
of  the  approximation  of  the  tubera  ischii  (see  Fig.  384,  p.  780). 
It  frequently  descends  transversely,  or  with  the  occiput  rotating 
somewhat  backward,  and  passes  through  the  outlet  entirely 
behind  the  tubera  ischii.  This  mode  of  delivery  resembles  that 
which  is  usual  with  the  lower  animals.  The  joints  in  this  form  of 
pelvis  have  not  uncommonly  been  found  somewhat  yielding,  and  it 
is  recorded  that  in  some  cases  space  between  the  tubera  ischii  has 
been  gained  by  widening  of  the  pubic  arch.  If  the  head  passes  the 
bony  outlet  in  a  transverse  position  or  nearly  so,  the  occiput  may 
afterwards  rotate  forwards  under  the  pressure  of  the  soft  parts.  In 
some  cases  a  compensatory  lordosis,  when  situate  very  low  down, 
forms  a  projection  overhanging  the  brim  [pelvis  ohtecta  or  spondy- 
lizeme),^  and  impedes  the  descent  of  the  head  into  it. 

Diagnosis — The  diagnosis  will  be  made  by  the  recognition  of 
the  spinal  deformity,  by  the  contraction  of  the  outlet,  especially  the 
small  distance  between  the  tubera  and  spines  of  the  ischium,  found 

1  Klien,  Archiv  f.  G-ynak.,  1896,  Bd.  1,  s.  1. 

*  Herrgott,  "  Die  Spondylizeme,"  Arch,  de  Tocologie,  1877,  p.  65. 


Rare  Forms  of   Pelvic  Deformity.         783 

on  vaginal  examination,  and  by  the  difficulty  of  reaching  the  upper 
part  of  the  sacrum. 

Prognosis. — In  the  statistics  collected  by  Champneys^  of  32 
labours  occurring  to  20  mothers,  the  results  were  that  9  mothers 
died,  that  is  to  say  45  per  cent,  of  the  mothers,  or  28*1  per  cent,  of 
deaths  in  proportion  to  labours  ;  13  children  died,  or  40*6  per  cent. 
These  results  doubtless  give  a  higher  mortality  than  the  average, 
the  gravest  cases  having  been  recorded.  Of  200  cases  collected  by 
Neugebauer^  only  44  ended  spontaneously,  and  24  per  cent,  of  the 
mothers  and  48'4  per  cent,  of  the  children  died.  Klieh  records  a 
foetal  mortality  of  40  i^er  cent.,  while  the  maternal  mortality  varied 
between  6*2  and  17  per  cent.,  depending  upon  the  degree  of  con- 
traction of  the  outlet  of  the  pelvis. 

Whenever  the  distance  between  the  ischial  tuberosities  is  less 
than  8  inches  (7'5  cm.)  delivery  is  likely  to  be  very  difficult. 

Treatment. — It  will  very  rarely  happen  that  interference  is 
called  for,  in  head  presentations,  until  the  head  has  descended  far 
into  the  pelvis.  If  in  any  case  assistance  is  required  while  the  head 
is  in  the  brim,  or  high  in  the  cavity  of  the  pelvis,  the  action  of 
forceps  is  more  favourable  than  in  the  flattened  pelvis,  since  the 
compression  of  the  head  produced  by  them  is  exactly  in  that  diameter 
of  the  pelvis  where  compression  is  wanted,  namely  in  the  transverse. 
Hence,  in  head  presentations,  version  should  never  be  performed. 
Forceps  should  be  tried,  if  there  appears  to  be  a  fair  prospect  of 
delivery  by  their  means.  If  craniotomy  is  found  necessary,  extraction 
by  the  cephalotribe  has  an  advantage  similar  to  that  of  extraction 
by  forceps.  The  blades  of  the  cephalotribe  being  kept  lateral,  the 
compression  exercised  is  precisely  in  the  direction  most  required. 
The  head  flattened  in  the  grasp  of  the  instrument  may  pass  in  part 
between  the  tubera  ischii,  even  when  the  distance  between  these 
is  not  above  2  inches.  If  the  outlet  does  not  give  room  for  the 
passage  of  a  living  child,  Csesarean  section  should  be  preferred  as  a 
first  choice,  especially  if  there  is  not  a  space  measuring  2^  inches 
in  its  smallest  diameter,  and  at  least  3^  inches  in  a  diameter 
bisecting  the  former  at  right  angles.  Symphysiotomy  will  afford 
a  greater  relative  increase  of  room  than  in  a  flattened  pelvis. 
Induction  of  premature  labour  will  be  desirable  in  case  of  any 
considerable  contraction  of  the  outlet,  if  the  patient  comes  under 
observation  before  full  term,  and  the  alternative  of  Csesarean  section 
is  not  preferred. 

1  See   ChampncyH,    "The   Obstetrics  of  the    Kyphotic    Pelvis,"   Trans.    Obst.  See. 
London,  1883,  Vol.  XXV.,  p.  UiC. 
'  Neugebauei',  Monatschr.  f.  Geb.  u.  Gyn.,  1805,  Bd.  1,  s.  347. 


784 


The  Practice  of   Midwifery. 


The  High  Assimilation  Pelvis. — This  title  has  been  given  to 
the  pelvis  resulting  from  a  fusion  of  the  last  lumbar  vertebra  with 
the  sacrum,  so  that  the  sacrum  is  made  up  of  six  vertebrae  instead 
of  five.  In  consequence,  the  sacro-vertebral  angle  and  the  inclina- 
tion of  the  pelvis  are  diminished.  The  effect  is  a  pelvis  of  which 
the  transverse  and  conjugate  diameters  at  the  brim  are  nearly 
equal,  or  which  may  be  slightly  contracted  transversely.  The 
lower  parts  of  the  innominate  bone  are  somewhat  inverted,  and 
the  lower  end  of  the  sacrum  tilted  forward,  so  that  the  pelvis  is 
somewhat  funnel-shaped,  but  less  so  than  the  kyphotic  pelvis. 
Thus  obstruction  to  labour  may  occur  at  the  outlet,  especially  if 

there  is  some  general  contraction 
in  addition. 

Whitridge  Williams^  has  drawn 
particular  attention  to  the  not 
infrequent  occurrence  of  slight 
degrees  of  contraction  of  the  pelvic 
outlet,  and  he  maintains  that  three- 
fourths  of  these  cases  are  associated 
with  a  high  assimilation  pelvis. 
The  shortening  may  occur  in  either 
the  transverse  or  the  antero-pos- 
terior  diameters  of  the  outlet.  The 
increased  shortening  of  the  trans- 
verse may  be  associated  with  such 
narrowing  of  the  pubic  arch  that 
only  the  posterior  portion  of  the 
outlet  lying  between  the  greatest 
transverse  diameter  and  the  lower  extremity  of  the  sacrum  is  avail- 
able for  the  passage  of  the  child's  head.  To  estimate  this  space  what 
Klien  has  termed  the  posterior  sagittal  diameter  of  the  outlet  should 
be  measured  from  the  centre  of  a  line  joining  the  two  ischial  tubero- 
sities to  the  posterior  surface  of  the  extremity  of  the  sacrum.  If 
it  measures  less  than  8*5  cm.,  and  is  associated  with  a  contracted 
transverse  diameter,  spontaneous  labour  is  likely  to  be  extremely 
difficult,  if  not  impossible. 


Fig.  385. — Pelvis  of  a  woman  who  had 
been  bedridden  from  infancy  up  to 
the  age  of  31.     (After  Blittner.) 


The  Low  Assimilation  Pelvis. — In  the  low  assimilation 
pelvis,  the  first  sacral  vertebra  is  assimilated  to  the  lumbar  spine, 
and  the  sacrum  consists  of  only  four  vertebrae.  This  pelvis  does 
not  lead  to  obstruction  in  labour. 


1  Whitridge   Williams,   Obstetrics,    1908,   p.    762  ;    Klien,   Volkmann's  Saml.  Klin. 
Vortrage,  1896,  N.  F.,  No.  169. 


Rare  Forms  of  Pelvic  Deformity.         785 


The  Bed-ridden  Pelvis. — The  bed-ridden  pelvis  is  analogous 
to  the  kyphotic  pelvis  in  the  shape  of  the  brim,  but  the  outlet  is 
not  contracted  in  the  same  way,  as  there  is  less  approximation  of 
the  tubera  ischii  and  narrowing  of  the  pubic  arch.  There  is  apt 
to  be  some  general  contraction  as  well  as  alteration  of  shape,  since 
the  disease  which  obliged  the  child  to  lie  in  bed  during  the  years 
of  development  is  likely  to  have  interfered  with  nutrition.  The 
explanation  of  the  shape  appears  to  be  that  in  the  absence  of  sitting, 

as  well  as  standing  and  walking,  the 
leverage  effects  of  the  reactions  to  the 
body-weight  in  widening  the  pelvis 
are  abolished.  Also,  the  sacrum 
growing  less  rapidly  than  the  rest  of 
the  pelvis,  the  brim  is  relatively 
narrower  transversely  than  that  of  a 
fcetus  or  child,  and  the  outlet  remains 
somewhat  funnel-shaped. 

The  Spondylolisthetic  Pelvis.^ — 
In  the  spondylolisthetic  pelvis 
(Fig.  387,  p.  786),  the  body  of  the  last 
lumbar  vertebra  is  dislocated  forward 
and  downward  over  the  anterior 
surface  of  the  sacrum.  The  other 
lumbar  vertebrae  are  carried  forward 
with  it,  hanging  over  and  projecting 
into  the  brim.  The  available  conju- 
gate diameter  is  thus  greatly  reduced, 
and  is  measured,  not  to  the  promon- 
tory of  the  sacrum,  but  to  the  nearest 
of  the  lumbar  vertebrae. 

A  hollow  is  formed  in  the  body 
above  the  sacrum.  The  stature  is  diminished,  the  abdomen 
shortened,  and  the  ribs  approximated  to  the  iliac  crests.  The 
resulting  figure  is  shown  in  Fig.  386. 

Causation. — This  dislocation  of  the  lumbar  vertebrae  is  produced 
after  birth  by  the  weight  of  the  body,  and,  in  the  majority  of  cases, 
it  is  due  to  a  fall  or  injury.  The  displacement  is  normally  prevented 
by  the  locking  between  the  articulating  processes  of  the  sacrum  and 
the  inferior  articulating  processes  of  the  last  lumbar  vertebra.  It 
is   rendered   possible   in   one  of   two  ways.     (1)  By  a  separation 


Fig.  386. — Figure  of  a  woman  with 
spondylolisthetic  pelvis.  (After 
Ahlfeld.) 


l'"rom  (nr/)V^vK(iv ,  a  vertchira,  oAiVSr/o-is,  Klidiiig  or  dlHlocatioii. 


M. 


50 


786 


The  Practice  of   Midwifery. 


between  the  anterior  and  posterior  halves  of  the  last  lumbar 
vertebra.  This  may  be  due  to  a  failure  of  development,  namely, 
a  want  of  union  between  the  arch  and  body  of  the  vertebra,  or  to 
a  destruction  of  that  union  by  fracture  of  the  pedicles.  The  body 
of  the  last  lumbar  vertebra  is  then  displaced  forward,  leaving  the 
articulating  processes  behind,  and  the  antero-posterior  diameter  of 
the  whole  vertebra  is  eventually  increased.  (2)  By  a  dislocation 
forward  of  the  whole  lumbar  vertebra  upon  the  sacrum.  This 
implies  a  destruction  of  the  union  between  the  pairs  of  articulating 
processes,  generally  through  fracture  of  the  articulating  processes 
of  the  sacrum.-"^  According  to  F.  Neugebauer,^  there  may  be  first 
a  dislocation  of  the  whole  lumbar  vertebra,  and  later  a  separation 


Fig.  387. — Spondylolisthetic  pelvis.     (After  Kilian.) 

of  the  anterior  and  posterior  halves,  owing  to  the  displaced  action 
of  the  body- weight.  He  maintains  that  this  is  accompanied  by  a 
gradual  elongation  of  the  interarticular  j)ortion  of  the  last  lumbar 
vertebra,  which  becomes  converted  into  a  long,  thin  lamina  of 
bone.  The  elongation  of  the  interarticular  portion  he  attributes  to 
imperfect  development  or  to  fracture  and  subsequent  stretching  of 
the  callus.  Deficient  ossification  of  the  laminae  of  the  fourth  and 
fifth  lumbar  vertebrae  is  not  at  all  uncommon,  and  may  be  associated 
with  similar  defects  in  the  laminae  of  the  upper  sacral  vertebrae.^ 

1  Arbuthnot  Lane,  however,  contends  that  the  whole  effect  may  result  from  pressure 
due  to  carrying  weights,  and  that  this  pressure  alone,  acting  over  a  long  period  of  time, 
may  cause  absorption  and  division  of  the  laminje  (Path.  Trans.,  Vol.  XXXVI.). 

2  Du  Bassin  vicie  par  le  Glissement  Vertebral,  Paris,  1884.  Also  in  Trans.  Obst.  Soc. 
London,  1884,  Vol.  XXVL,  p.  84. 

3  Blacker,  Trans.  Obst.  Soc.  London,  1900,  Vol.  XLIL,  p.  90  ;  Lawrence,  Trans.  Obst. 
Soc.  London,  1900,  Vol.  XLIL,  p.  75  ;  Neugebauer,  Spondylolisthesis  et  Spondylizfeme, 
1892. 


Rare  Forms  of   Pelvic  Deformity.         787 

The  change  in  the  pelvis  is  generally  produced  more  or  less 
gradually  by  the  action  of  the  body-weight.  It  is  usually  accom- 
panied by  inflammatory  changes  in  the  bones,  and  the  sacrum  and 
some  of  the  lumbar  vertebrse  often  become  fused  into  one  mass. 
In  well-marked  cases  the  inferior  articular  process  of  the  last 
lumbar  vertebra  and  the  superior  articular  process  of  the  first 
sacral  vertebra,  as  well  as  the  inferior  articular  process  of  the  fourth 
lumbar  vertebra  and  the  superior  of  the  fifth  lumbar,  become  firmly 
anchylosed  together. 

In  some  cases  the  spines  of  the  lumbar  vertebrge  become  greatly 
thickened,  and  either  fused  into  one  mass  with  each  other,  and 
with  the  spine  of  the  first  piece  of  the  sacrum,  or  united  by  joints. 
This  proves  that  excessive  weight  has  been  in  action,  and  that  it 


Fig.  388. — Bony  growth  of  the  sacrum. 

has  been  transmitted,  in  part,  by  the  spines  instead  of  by  the  bodies 
of  the  vertebrge. 

Resulting  Changes  in  the  Pelvis. — As  the  whole  spine  sinks  not 
only  downward  but  forward  over  the  pelvis,  the  pelvic  inclination 
must  be  diminished,  to  preserve  the  balance  in  standing  or  sitting. 
The  reactions  to  the  body-weight  tend  to  increase  the  same  effect 
by  pushing  the  anterior  half  of  the  pelvis  upward,  as  in  other 
cases  in  which  the  line  of  incidence  of  the  body-weight  is  displaced 
forward,  such  as  the  rachitic  and  malacosteon  pelves.  In  severe 
cases,  such  as  that  shown  in  Fig.  387,  the  inclination  is  actually 
reversed,  the  top  of  the  sacrum  being  lower  than  the  symphysis 
pubis.  The  last  lumbar  vertebra  pushes  the  top  of  the  sacrum 
backwards  (see  Fig.  387),  and  the  lower  end  of  the  sacrum  is  thus 
rotated  forward,  narrowing  the  pelvic  outlet  antero-posteriorly. 
In  severe  cases  this  is  increased  ]jy  pressure  on  the  lower  part  of 
the  sacrum  in  sitting.     Owing  to  the  diminished  pelvic  inclination 

50—2 


788 


The  Practice  of   Midwifery. 


Fig.  389. — Sacral  exostosis  filling  the 
pelvis. 


the  sacrum  sinks  deeply,  under  the  pressure  of  the  body-weight, 
in  the  direction   of  the  coccyx,   separating   the   iha.      Thus   the 

posterior  crests  of  the  iha  are 
wide  apart,  and  the  Dist.  Cr.  II.  is 
increased.  Increased  traction  on 
the  sacro-sciatic  hgaments,  owing 
to  the  recession  of  the  sacrum, 
draws  the  tubera  and  spines  of  the 
ischium  inward.  Also,  in  conse- 
quence of  the  diminished  pelvic 
inclination,  increased  strain  is 
thrown  upon  the  ilio-femoral  liga- 
ments, as  in  the  kyphotic  pelvis 
(see  p.  781),  but  not  to  so  great 
an  extent,  because  the  body-weight 
is  not  transmitted  to  the  pelvis  so 
far  back  as  in  that  case.  The 
tension  of  the  ilio-femoral  liga- 
ments increases  the  tendency  to 
inward  rotation  of  the  spines  and 
tubera  of  the  ischium,  as  in  the  kyphotic  pelvis.  Hence  the 
pelvic  outlet  is  contracted  transversely  as  well  as  longitudinally. 

The  spondylolisthetic 
pelvis,  in  its  fully  developed 
form,  is  very  rare,  but  accord- 
ing to  F.  Neugebauer,  minor 
degrees  of  it  are  commoner 
than  has  been  supposed. 
Since  the  development  of  the 
deformity  is  largely  due  to 
carrying  excessive  weights, 
it  is  much  rarer  in  women 
than  in  men. 

Diagnosis. — There  may  be 
a  history  of  injury  in  child- 
hood or  youth,  followed  by 
pain  in  the  body,  change  of 
figure,  and  perhaps  loss  of 
stature.  Walking  is  affected 
by  the  deformity,  and  is  waddling  in  character.  The  buttocks 
project  much  backward;  the  posterior  crests  of  the  ilia  and  top  of 
the  sacrum  are  very  prominent,  while  above  is  a  deep  cavity 
corresponding  to  the  lumbar  vertebrae.      The  edges  of  the  ribs  are 


Fig.  390. — Minor  degree  of  deformity  from 
exostosis  of  the  cristje  of  the  pubis. 


Rare  Forms  of   Pelvic  Deformity.         789 


too  near  to  the  iliac  crests,  the  abdomen  shortened  and  prominent. 
On  vaginal  examination  the  prominence  produced  by  the  lumbar 
vertebrae  may  be  distinguished  from  a  projecting  sacrum  by  the 
absence  of  the  sacral  wings.  Sometimes  the  bifurcation  of  the 
aorta  and  iliac  arteries  can  be  reached,  being  displaced  much 
downward.  The  contraction  of  the  outlet  will  also  be  a  point  of 
distinction  from  the  flattened  reniform  pelvis. 

Prognosis — Swedelin^  has  collected  the  statistics  of  19  cases. 
In  these  there  were  48  deliveries,  31  at  full  term,  10  induced 
premature  labours,  4  spontaneous  premature  labours,  3  abortions. 
Of  the  19  mothers  8  died,  or 
42  per  cent.,  1  after  an  abor- 
tion, only  3  after  Csesarean 
section.  Of  the  children  16 
passed  the  genital  canal  alive, 
4  were  delivered  by  Csesarean 
section.  It  is  clear  from  this 
that  in  the  severer  degrees  of 
deformity  the  obstacle  to 
delivery  is  very  great,  but  in 
slighter  degrees  it  may  be 
overcome  by  the  natural 
powers,  or  by  forceps  or  ver- 
sion. In  some  cases  increase 
of  difficulty  in  successive 
labours  has  been  noted, 
apparently  due  to  increase  in 
the  deformity. 

Treatment.  —  In  milder 
degrees  of  deformity  the 
choice  between  induction  of  premature  labour  or  abortion,  the  use  of 
forceps,  version,  craniotomy,  symphysiotomy,  or  Csesarean  section, 
will  be  similar  to  that  in  the  reniform  flattened  pelvis,  the  virtual 
conjugate,  measured  to  the  nearest  point  of  the  lumbar  vertebrse, 
being  taken  for  the  estimation  instead  of  the  true  conjugate.  In 
more  extreme  degrees  the  contraction  of  the  outlet  may  complicate 
the  question  by  rendering  access  with  instruments  difficult,  as  well 
as  by  impeding  the  passage  of  a  living  child,  and  so  may  turn  the 
scale  in  favour  of  Csesarean  section. 


Fig.  391. — Cancerous  growths  from  the  bones 
of  the  pelvis,  causing  deformity. 


Pelvis  deformed   by  Outgrowths. — Obstruction  of  the  pelvis 
caused    by  exostosis    is    rare,  but   may  be  so  great  as  to  render 


1  Arch,  flir  Gynak.,  Bd,  22,  Hft.  2. 


790 


The  Practice  of   Midwifery. 


delivery  through  the  genital  canal  impossible.  The  most  common 
situation  of  growth  is  the  upper  half  of  the  sacrum.  The  growth 
has  then  to  be  distinguished  from  a  projecting  promontory  by  its 
shape,  and  by  the  external  measurements  of  the  pelvis.  In  cases 
of  multiple  exostoses  throughout  the  body,  there  may  be  multiple 
exostoses  also  in  the  pelvis.  These  cause  more  difficulty  if  they 
are  on  opposite  sides  of  the  pelvis,  and  easily  cause  laceration  of 


Fig.  392. — Enchondroma  of  sacrum  obstructing  labour.  Porro's  operation 
with  intraperitoneal  treatment  of  stump.  Death  from  uremia.  (Univ. 
Coll.  Hosp.  Med.  School  Mus.)  2 

the  uterus  through  pressure  and  friction  even  when  they  are 
comparatively  small.  The  pelvis  in  such  cases  is  often  found  to 
be  in  addition  generally  contracted  or  rachitic,^  and  the  difficulty 
is  thus  increased.  Growths  may  be  enchondromata,^  osteo- sarcomata 
or  carcinomata  as  well  as  purely  bony  (see  Fig.  392),  In  the  case  of 
rheumatoid  arthritis,  with  bony  outgrowths,  affecting  the  hip-joints, 
osteophytes  may  form  also  on  adjacent  parts  of  the  pelvis  (Fig.  390, 

1  Neuenzeit,  Becken  mit  multipelen  Exostosen,  I.  Dissert.,  Breslau,  1872. 

2  Spencer,  Trans.  Obst.  Soc.  London,  1896,  Vol.  XXXVIII.,  p.  389. 


Rare  Forms  of   Pelvic  Deformity.         791 

p.  788).  In  other  cases  spiculse  or  ridges  of  bone  projecting 
inwards  may  form  at  the  insertion  of  ligaments  or  tendons  or  along 
the  natural  edges  of  bone.  These  not  only  occupy  some  space,  but 
may  press  upon  and  lacerate  the  uterus  in  labour.  Cases  are  also 
on  record  in  which  the  callus  resulting  from  fractures  of  the 
pelvis  has  encroached  upon  the  pelvic  cavity,  and  obstructed 
labour. 

Treatment. — If  the  growths  are  bony  they  will  be  incompres- 
sible, and  the  treatment  must  be  decided  according  to  the  amount 
of  space  left,  as  in  the  case  of  pelvic  deformity.  If  projecting 
points  or  edges  of  bone  are  detected,  the  tendency  of  these  to 
cause  laceration  of  the  uterus  must  be  remembered.  Much  force 
must  not  be  used  in  extraction  by  forceps  in  order  to  secure  a 
living  child,  and  there  must  not  be  too  great  hesitation  in  resorting 
to  embryotomy.  In  the  case  of  growths  filling  up  the  main  part 
of  the  pelvis,  Csesarean  section  may  be  necessary.  As  a  rule, 
extraction  after  embryotomy  is  possible,  if  there  is  a  minimum 
diameter  not  less  than  2  inches,  and  a  diameter  bisecting  this  at 
right  angles  not  less  than  3J  inches ;  but  unless  these  measures 
are  as  much  as  3  and  3^  inches  respectively,  C^esarean  section  is 
generally  preferable  as  a  first  choice  if  it  can  be  performed  under 
the  most  favourable  conditions. 


Chapter  XXXI. 

INDUCTION  OF  PREMATURE  LABOUR  AND 
ARTIFICIAL  ABORTION. 

Induction  of  Prematuee  Labour. 

The  induction  of  premature  labour,  as  a  conservative  operation 
both  for  the  mother  and  the  child,  was  first  proposed  and  practised 
in  this  country ;  and,  as  a  means  of  deUvery  in  cases  of  contracted 
pelvis,  has  generally  been  held  in  higher  esteem  in  Great  Britain 
than  on  the  Continent.  By  induction  of  premature  labour  it  is 
intended  to  save  the  child,  or,  at  any  rate,  to  give  it  a  chance  of 
surviving.  The  operation  is  called  induction  of  artificial  abortion 
when  performed  at  too  early  a  stage  of  pregnancy  to  allow  this. 
Induction  of  premature  labour  is,  therefore,  generally  performed 
not  earlier  than  about  the  thirtieth  week,  and,  in  most  cases, 
not  earlier  than  the  thirty-fourth  week.  Before  that  time  there  is 
but  little  chance  that  the  child  will  be  reared,  especially  in 
hospital  practice,  or  when  the  parents  are  poor  and  the  infant  is 
not  likely  to  receive  the  most  constant  and  careful  attention. 
The  operation  may  be  called  for  in  the  interest  of  the  mother  or 
the  child,  or  in  that  of  both.  The  following  are  the  principal 
indications  for  it. 

Indications  for  the  Operation. 

(1.)  Pelvic  Contraction. — In  moderate  degrees  of  pelvic  con- 
traction the  operation  is  performed  mainly  for  the  sake  of  the 
child,  but,  in  some  measure  also,  for  that  of  the  mother.  The 
conditions  under  which  it  should  be  undertaken,  and  the  date  of 
pregnancy  which  should  be  chosen,  have  already  been  discussed 
(see  p.  755).  Since  the  difficulty  arises,  not  from  the  absolute 
size  of  the  pelvis,  but  from  its  relation  to  that  of  the  child,  even  an 
habitually  large  size  of  the  fcetus  or  a  continuation  of  the  pregnancy 
beyond  the  normal  time  (post-maturity  of  the  foetus)  may  be,  in 
some  cases,  an  adequate  reason  for  the  induction  of  labour,  though 
no  manifest  contraction  of  the  pelvis  is  revealed  on  measurement. 
In  such  cases,  if  a  child  has  been  stillborn  after  difficult  forceps 
delivery,  labour  may  be  induced  three  or  four  weeks  before  full  term. 


Induction   of   Premature   Labour,    Etc,     793 

(2.)  Diseases  endangering  the  Mother's  Life.— In  this  case 
the  operation  is  performed  mainly  in  the  interest  of  the  mother, 
but  it  may  be  undertaken  with  much  less  reluctance  when  the 
pregnancy  is  so  far  advanced  that  the  child  is  not  likely  to  be 
sacrificed.  It  may  also  conduce  to  the  preservation  of  the  child, 
which  shares  in  any  danger  to  the  mother's  life.  In  cases  of 
eclampsia  or  placenta  prsevia  there  need  be  little  hesitation  about 
proceeding  to  the  induction  of  labour.  Other  conditions  occa- 
sionally calling  for  the  operation  are  albuminuria,  especially  when 
there  is  much  oedema,  grave  diseases  of  heart  or  lungs,  severe 
jaundice,  hydramnios,  especially  if  early  and  acute,  severe  chorea,^ 
pernicious  anaemia,  leucaemia,^  ascites,  and  some  abdominal  tumours. 
Uncontrollable  vomiting,  which  endangers  life,  may  sometimes  be 
an  indication,  but  this  more  frequently  calls  for  the  consideration 
of  the  induction  of  abortion.  It  has  been  proposed  by  some  to 
induce  labour  in  the  interest  of  the  child  alone,  when  the  mother's 
condition  is  hopeless,  or  she  is  dying.  This,  however,  is  not 
generally  desirable,  since,  in  most  cases,  it  would  risk  a  shortening 
of  the  mother's  life  or  her  immediate  death,  and  the  mother's 
welfare  should  always  be  considered  paramount. 

(3.)  Habitual  Death  of  the  Foetus.— Habitual  death  of  the 
foetus  at  the  certain  period  of  pregnancy,  within  the  last  two 
months,  is  generally  stated  as  an  indication  for  the  induction  of 
labour.  It  is  only,  however,  in  very  rare  cases  that  the  plan  has 
been  adopted  with  success.  Most  frequently  the  cause  is  syphilis, 
and  in  such  cases  the  child  would  probably  be  already  too  gravely 
affected  to  survive.  Mercurial  treatment  of  the  mother  would 
afford  a  better  prospect.  Induction  of  labour  may  be  performed 
if  the  cause  is  probably  placental  degeneration  or  inanition, 
especially  when  these  result  from  anaemia  or  some  condition 
other  than  syphilis  in  the  mother.  The  operation  may  be  then 
performed  a  little  before  the  time  at  which,  from  the  mother's 
sensations,  the  death  is  presumed  to  have  occurred  in  previous 
pregnancies. 

Methods  of  Operating. 

Puncture  of  the  Membranes.^ — Evacuation  of  the  liquor 
amnii  by   puncture   of  the  membranes   was   the   earliest  method 

1  French  and  ificks,  I'lactilinncr,  IDOf),  Vol.  LXXVL,  p.  178. 

2  Herman,  Trans.  Obst.  Soc.  London,  1901,  Vol.  XLI.IL,  p.  2;i4. 
'  Von  Herff,  Volkmann's  Haiuml.  Klin.  Vortrage,  No.  880. 


794  The  Practice  of   Midwifery. 

adopted  for  the  induction  of  labour,  and  was  the  method  recom- 
mended as  the  result  of  the  great  consultation  of  obstetric 
physicians  in  London  on  this  subject  in  1756,  It  is  a  perfectly 
certain  method,  since  it  never  fails  to  bring  on  labour  sooner  or 
later.  It  has  also  the  advantage  that  it  can  generally  be  carried 
out  with  less  inconvenience  or  discomfort  to  the  patient  than  any 
other  method.  Its  disadvantage  is  that  it  does  away  with  the 
fluid  wedge  of  the  bag  of  membranes  as  a  dilator  of  the  cervix. 
It  follows  that,  although  in  many  cases  labour  goes  on  satisfac- 
torily, and  the  child  is  saved,  yet  it  may  happen  that  the  first 
stage  of  labour  is  protracted,  as  it  is  apt  to  be  after  spontaneous 
premature  rupture  of  the  membranes.  The  child  is  then  frequently 
sacrificed  from  its  exposure  to  prolonged  pressure,  unsupported  by 
the  liquor  amnii,  a  premature  child  having  less  power  of  endurance 
than  one  at  full  term.  This  disadvantage  has  led  to  the  method  of 
puncture  of  the  membranes  being  abandoned  by  most  obstetricians 
as  the  ordinary  mode  of  induction  of  labour  when  performed  mainly 
in  the  interest  of  the  child,  although  its  dangers  have  perhaps  been 
exaggerated.^  There  is  one  condition,  however,  in  which  puncture 
of  the  membranes  is  the  best  method,  namely,  eclampsia,  in  which 
there  is  an  advantage  in  relieving  the  tension  of  the  uterus  at  once. 
Puncture  of  the  membranes  is  an  uncertain  method  as  to  time,  and 
therefore,  by  itself,  it  is  not  adapted  for  those  cases  in  which  speedy 
delivery  is  called  for.  When  followed  up,  however,  by  artificial 
dilatation  of  the  cervix  it  is  the  most  rapid  of  all  methods.  In  the 
ordinary  case  of  induction  of  labour  on  account  of  pelvic  contraction, 
in  the  interest  of  the  child,  it  should  not  be  chosen. 

Introduction  of  a  Flexible  Bougie  into  the  Uterus. — This 
method  consists  in  the  introduction  of  an  elastic  male  catheter  or 
bougie  into  the  uterus  between  the  membranes  and  the  uterine 
wall.  The  mode  in  which  it  acts  is  by  exciting  reflex  stimulus, 
partly  by  the  separation  between  the  membranes  and  the  uterus 
thus  effected,  but  mainly  by  the  presence  of  the  bougie  itself  in 
contact  with  the  uterine  surface.  Hence  the  special  merit  of  this 
method  is  that  labour  pains  come  on  in  a  manner  resembling  as 
closely  as  possible  the  onset  of  natural  labour,  and  that  the  bag  of 
membranes  is  preserved  for  the  dilatation  of  the  os  in  the  natural 
way.  There  is  one  drawback  to  the  operation,  namely,  that  the 
bougie  may  separate  the  placenta  and  cause  haemorrhage.  But  it  is 
found  practically  that  it  does  not  often  happen,  especially  if  the 

1  Reynier,  Beitrage  f.  Geb.  u.  Gyn.,  1905,  Bd.  9.  For  full  account  see  Williamson, 
Journ.  Obst.  and  Gyn,  Brit.  Emp.,  1905,  Vol.  VIII.,  No,  4,  p.  257. 


Induction  of   Premature   Labour,   Etc.     795 

bougie  is  not  passed  more  than  about  seven  inches  within  the  external 
OS.  There  is  generally  room  for  this  length  below  the  placental 
site.  It  is  also  possible  that  the  membranes  may  be  ruptured  in 
the  attempt  to  introduce  the  bougie,  especially  if  the  operator  is  not 
very  practised.  If  this  happens,  the  method  is  simply  converted 
into  that  of  puncturing  the  membranes,  with  the  difference  only 
that  the  presence  of  the  bougie  furnishes  an  additional  stimulus  to 
reflex  action. 

The  time  required  for  the  induction  of  labour  by  this  method 
varies  according  to  the  height  to  which  the  bougie  is  passed  into 
the  uterus,  as  well  as  according  to  the  susceptibility  of  the 
individual  to  reflex  stimulus.  As  a  rule,  provided  that  the 
bougie  is  fairly  well  introduced,  labour  pains  commence  within 
twenty-four  hours,  and  labour  is  usually  completed  within  forty- 
eight  hours.  Sometimes  pains  commence  immediately,  and  labour 
is  completed  well  within  twenty-four  hours.  The  method  is  not 
adapted  for  cases  in  which  very  rapid  delivery  is  called  for,  but 
labour  may  be  accelerated  by  artificial  dilatation  of  the  cervix,  as 
soon  as  labour  pains  have  fairly  commenced. 

Mode  of  operating. — This  method  is  one  of  the  best  for  the 
ordinary  case  of  induction  of  labour  in  moderate  pelvic  contrac- 
tion, in  the  interest  mainly  of  the  child.  If  the  cervix  is  closed, 
and  high  up,  hot  vaginal  irrigations  or  injections  may  be  employed 
every  two  or  three  hours  for  twelve  hours  preceding.  These  may 
have  the  effect  of  softening  the  cervix,  and  inducing  some  com- 
mencement of  dilatation.  The  best  instrument  to  use  is  not  a 
catheter,  which  admits  air  into  the  uterus  through  the  opening  at 
the  end,  but  a  hollow  bougie,  which  can  be  used  with  a  stylet,  if 
desired.  Bougies  made  of  flexible  celluloid  are  more  non-absorbent 
than  the  ordinary  gum-elastic  bougies.  The  bougie  should  be 
sterilised  by  soaking  in  1  in  1,000  perchloride  of  mercury  lotion 
for  twelve  hours  and  softened  in  warm  water  sufficiently  to  make  it 
pliant,  but  it  should  not  be  so  soft  as  to  double  up  and  be  incapable 
of  any  direction.  Hands  and  bougie  should  be  carefully  disinfected 
with  perchloride  or  iodide  of  mercury,  1  in  1,000 ;  and  the  vagina 
should  also  be  irrigated  with  the  same  solution. 

For  the  operation  the  patient  should  be  placed  at  first  on  her  left 
side,  preferably  under  an  anaesthetic.  The  stage  at  which  the 
accident  of  rupturing  the  membranes  is  most  likely  to  occur  is  when 
the  point  of  the  bougie  is  passing  the  internal  os.  The  bougie  may 
generally  be  guided  into  the  cervix,  held  between  the  index  and 
middle  fingers.  If  possible,  the  index  finger  should  be  passed  up 
to  the  internal  os,  and  guide  the  tip  of  the   bougie  between  the 


79^  The  Practice  of   Midwifery. 

membranes  and  the  uterine  wall,  so  that  rupture  of  the  membranes 
is  avoided.  The  bougie  will  generally  pass  much  more  readily 
along  the  posterior  uterine  wall  than  along  the  anterior,  because  the 
direction  of  that  wall  is  more  nearly  in  a  line  with  the  cervix  and 
the  vagina  (see  Fig.  114,  p.  159).  If,  however,  it  can  be  guided  to 
one  side,  or  somewhat  toward  the  front,  there  is  less  likelihood  that 
it  will  encounter  the  placenta. 

If  the  cervix  is  not  wide  enough  to  admit  the  finger,  previous 
dilatation  may  be  carried  out  with  Hegar's  dilators,  or  the  stylet 
may  be  used  to  facilitate  the  direction  of  the  bougie  until  the  point 
has  passed  the  internal  os,  and  reached  a  safe  position  between  the 
uterine  wall  and  the  membranes.  The  stylet  should  have  a  very 
gentle  curve  given  to  it,  considerably  less  than  that  of  a  male 
catheter.  For  introduction  through  the  cervix  the  bougie,  made 
firm  by  its  stylet,  is  maniiDulated  like  the  uterine  sound.  After  the 
point  of  the  bougie  has  passed  through  the  internal  os,  the  stylet  is 
withdrawn,  and  the  bougie  afterwards  pushed  on  without  it,  until 
it  has  passed  deej)ly  enough. 

For  the  further  passage  of  the  bougie,  after  its  point  has  once 
entered  the  uterine  cavity,  it  is  often  convenient  to  place  the 
patient  on  her  back.  The  index  and  middle  fingers  are  then 
introduced  into  the  vagina,  the  bougie  grasped  between  their  tips 
a  little  below  the  cervix,  and  so  gradually  insinuated  further  and 
further  into  the  uterus  until  about  seven  inches  have  passed.  If  it 
is  found  that  it  can  be  pushed  on  without  resistance  until  the  lower 
end  is  within  the  vagina,  the  support  of  the  posterior  vaginal  wall 
will  generally  keep  it  in  position,  without  any  further  means  being 
used.  But  generally,  there  will  be  four  or  five  inches  outside  the 
cervix,  and  the  lower  end  will  be  outside  the  vulva.  Some  means 
should  then  be  adopted  to  prevent  its  slipping  out.  The  most  con- 
venient is  the  following.  The  length  remaining  outside  the  cervix 
is  measured  by  the  forefinger,  and  an  equal  length  is  broken  off  with 
a  pair  of  pliers  from  the  lower  end  of  the  stylet.  This  piece  of 
stylet  is  passed  into  the  bougie,  thus  making  rigid  onl}^  that  portion 
which  is  outside  the  uterus,  and  tapes  are  fastened  to  the  ring  of 
the  stylet.  Two  of  these  are  carried  up  in  front,  two  behind,  and 
fastened  to  a  belt  round  the  waist,  so  keeping  the  bougie  in  position. 

Bleeding  to  the  extent  of  a  few  drops  often  occurs  from  the 
separation  of  the  membranes.  If,  however,  any  considerable 
bleeding  occurs,  indicating  that  the  placenta  has  been  touched, 
the  operator  should  abstain  from  pushing  the  bougie  any  further 
in  the  same  direction.  If  bleeding  continues  afterwards  to  any 
important  extent,  the  membranes  should  be  punctured. 


Induction  of   Premature   Labour,   Etc.     797 

If  labour  pains  do  not  come  on  satisfactorily,  the  reason 
generally  is  that  the  bougie  has  not  penetrated  far  enough.  It 
may  then,  on  the  following  day,  be  reintroduced,  or  a  second 
bougie  may  be  passed  in  a  somewhat  different  direction.  If,  after 
the  commencement  of  pains,  the  first  stage  of  labour  is  long  pro- 
tracted, or  if  a  rising  pulse  indicates  the  expediency  of  accelerating 
it,  hydrostatic  dilators  should  be  used  to  expand  the  cervix. 

Use  of  Hydrostatic  Dilators  or  Bags. — If  the  cervix  is 
patent   enough   to   admit  one   finger,  as  is  not  uncommonly  the 


•I 


h 


Fig.  393.— Horrocks'  Maieutic, 
natural  size. 


Fig.  394.— Maieutic,  fixed 
on  catheter. 


case  in  multiparse,  dilatation  may  be  commenced  by  introducing 
one  of  the  smaller  varieties  of  hydrostatic  dilators.  The  dilatation 
sets  up  pains  through  reflex  action ;  labour  is  generally  started 
by  the  time  that  any  considerable  dilatation  has  been  effected, 
and  afterwards  goes  on  automatically.  If  the  pains  cease 
after  the  smallest  dilator  has  been  expelled,  larger  ones  must 
be  introduced  afterwards.  Most  operators  find  that,  when 
the  cervix  is  small,  Barnes'  bag  and,  still  more,  ChamiDetier 
de  liibes'  bag,  cannot  be  introduced  without  some  previous 
dilatation,  either  by  tents  or  mechanical  dilators,  such  as 
Hegar's.  Hydrostatic  l>ags  of  a  smaller  size  have  therefore  been 
used.  Thus  Tarnier's  dilator  consists  of  an  india-rubber  tube, 
terminating  in  a  small  ball ;  and  this  may  be  used  to  start  labour, 


798 


The  Practice  of   Midwifery. 


being  introduced  by  a  special  form  of  sound.  Other  accoucheurs 
have  adopted  india-rubber  toy  balloons  for  the  purpose.  At 
Guy's  Hospital  Horrocks'  Maieutic  (Figs.  393,  394),  consisting  of 
small  bags  of  various  sizes,  made  of  very  thin  india-rubber,  has 
been  much  used.  The  smallest  bag,  when  unstretched,  measures 
about  IJ  by  f  inch,  and,  when  dilated,  expands  into  a  nearly 
spherical  form.     It  is  used  in  the  following  manner  : — 

The  bag  is  tied  over  the  end  of  a  No.  6  gum  elastic  catheter, 
by  means  of  which  it  is  introduced.  It  is  then  filled  with  some 
weak  antiseptic  lotion  to  an  extent  previously  determined  sufficient 
to  completely  distend,  but  not  to  burst,  it. 

This  method   acts   rather   by   exciting   reflex    action    than    by 


Fig.  395.— Maieutic  distended  hi  situ.     The  dotted  line  above  represents  amnion. 
The  cervical  canal  is  represented  as  open  merely  for  the  sake  of  clearness. 

directly  dilating,  although  some  dilatation  is  effected  if  the  bag 
is  expelled.  It  is  probably  the  most  perfect  method  of  inducing 
labour,  since  it  has  the  advantage,  as  compared  with  the  use  of 
the  bougie,  that  there  is  no  risk  of  separating  the  placenta.  The 
only  difficulty  is  to  get  the  rubber  bags  made  thin  enough  to  dilate 
easily  by  hydrostatic  pressure  and  yet  strong  enough  not  to  burst. 

The  method  is  uncertain  as  regards  the  time  required,  like  the 
use  of  the  bougie.  In  favourable  circumstances  labour  may  be 
completed  in  twenty-four  hours,  but  several  days  are  sometimes 
required.  If  the  bag  bursts,  another  should  be  introduced.  If 
pains  are  quiescent  twelve  hours  after  its  introduction,  it  should  be 
introduced  afresh,  since  the  fluid  is  often  found  to  have  oozed  out 
of  the  bag.     If  it  is  expelled,  and  the  pains  cease,  it  is  generally 


Induction   of   Premature   Labour,   Etc.     799 

better  to  use  a  Barnes'  or  Champetier  de  Ribes'  dilator,  which  the 
cervix  will  now  admit,  since  the  larger  bags  of  very  thin  rubber  do 
not  answer  so  well.  Frequently  labour  will  go  on  automatically 
after  the  bag  is  expelled,  especially  if  the  patient  is  allowed  to  be 
up  and  about  in  her  room. 

Champetier  de  Ribes'  dilating  bag,  already  described  (see  p.  640), 
was  invented  for  the  purpose  of  inducing  labour.  The  design  is 
that  the  bag  when  placed  above  the  internal  os  and  dilated  should 
assume  the  diameter,  approximately,  of  a  foetal  head,  leaving  the 
maternal  efforts  to  expel  the  foreign  body.  By  this  means,  not  only 
is  the  uterus  stimulated  to  contract,  but,  when  the  bag  is  expelled, 
no  further  difficulty  is  experienced  from  the  obstruction  of  the 
soft  parts. 

The  inventor  declares  that,  in  all  his  cases,  multiparas  and 
primiparse  alike,  he  has  been  able  to  pass  his  index  finger  into  the 
uterus,  to  strip  ofi'  the  membrane  and  explore,  and  satisfy  himself 
as  to  the  direction  he  should  give  the  bag.  Chloroform  is  to  be 
given,  if  necessary ;  and,  as  soon  as  two  fingers  can  be  inserted  as 
far  as  their  first  articulation,  the  bag  can  be  introduced.  The 
further  manipulation  has  been  already  described  (see  p.  640). 

Besides  being  used  as  the  primary  method  for  induction,  this 
plan  may  also  be  adopted  as  an  adjunct,  especially  to  the  introduc- 
tion of  a  flexible  bougie,  or  smaller  bag,  when  labour  is  not  set 
up,  or  does  not  progress  rai3idly  enough.  The  introduction  will 
then  be  generally  facilitated  by  some  dilatation  of  the  os  having 
already  taken  place.  This  proceeding  is  especially  desirable  when 
the  membranes  have  been  accidentally  ruptured  in  the  introduction 
of  the  bougie,  and  is  a  certain  and  speedy  method,  the  average 
length  of  time  elapsing  before  the  onset  of  labour  being  about 
fifteen  hours. -^ 

As  a  primary  method  it  has  the  disadvantage  that  it  does  not 
imitate  so  closely  as  the  bougie  the  natural  process  of  labour,  and 
involves  some  risk  of  displacement  of  the  presenting  head,  prolapse 
of  the  cord,  and  consequent  danger  of  the  death  of  the  child. 

If  the  bag  is  properly  introduced,  it  should  never  burst,  but  its 
use  appears  to  involve  a  slightly  greater  risk  to  the  mother  than 
the  use  of  the  bougie,  and  it  certainly  increases  the  danger  to  the 
child.  For  these  reasons  it  is  not  employed  so  much  for  the 
induction  of  labour  now  as  it  was  on  its  first  introduction. 

The  Vaginal  Douche. — The  method  of  inducing  labour  by 
repeated  douches  of  cold  or  hot  water  directed  against  the  cervix 

J  Kromer,  Monatschr.  f.  Geb.  u.  (iyri.,  1904,  Bfl.  20,  s.  903. 


8oo  The  Practice  of   Midwifery. 

uteri  was  introduced  by  Kiwisch,  of  Wurzburg,  in  1836.  The 
mode  in  which  this  treatment  acts  is  mainly  that  of  exciting  the 
uterus  by  reflex  action,  set  up  partly  by  the  distension  of  the 
vagina,  partly  by  the  impression  of  heat  or  cold.  Hot  water  is 
the  most  effective  in  stimulating  the  uterus,  as  is  illustrated  by 
its  efficacy  in  the  arrest  of  jpost-partum  hsemorrhage,  and  thus  the 
douche  answers  best  if  used  at  a  temperature  of  110°  to  115°  F. 
Besides  the  reflex  stimulus,  some  effect  may  also  be  produced  by 
the  water  penetrating  the  cervix  uteri,  when  slightly  dilated,  and 
partially  separating  the  membranes  in  its  vicinity.  The  hot  water 
also  tends  to  soften  and  dilate  the  cervix  and  so  assist  its  dilatation. 
The  injections  may  be  made  with  an  irrigator  elevated  above  the 
bed,  and  of  sufficient  size  to  contain  about  a  gallon  of  water. 

This  method  of  induction  met  at  first  with  considerable  favour 
on  account  of  its  apparent  simplicity  and  safety.  It  is,  however,  a 
rather  tedious  and  somewhat  uncertain  method,  and  the  repeated 
manipulations  favour  the  occurrence  of  sepsis. 

The  vaginal  douche  is,  therefore,  now  not  often  practised  as  the 
sole  method  of  induction,  and  is  generally  limited  to  treatment 
preparatory  to  the  use  of  other  means,  especially  to  the  passing 
of  an  elastic  bougie  into  the  uterus.  If  the  douche  is  used  for 
about  twelve  hours  at  intervals  of  two  hours,  it  tends  to  soften 
and  slightly  dilate  the  cervix,  and  sometimes  sets  up  some 
commencement  of  uterine  action. 

The  following  are  other  methods  which  have  been  used  for  the 
induction  of  labour,  but  are  not  recommended  for  adoption  : — 

Oxytocic  Drugs. — Labour  was  formerly  sometimes  induced 
by  oxytocic  drugs,  such  as  ergot.  Their  action,  however,  is  very 
uncertain,  and  frequently  repeated  doses  have  often  been  found 
necessary.  A  graver  objection  is  that  the  results  to  the  child  are 
very  unfavourable,  in  consequence  of  the  tonic  contraction  of  the 
uterus  which  is  apt  to  be  excited.  This  method  has  therefore  been 
abandoned. 

Intra-uterine  Injections, — An  effective  and  also  a  rapid 
mode  of  inducing  labour  is  the  injection  of  a  considerable  quantity 
of  warm  water  into  the  uterus,  especially  if  the  injection  is  made 
by  means  of  a  tube  passed  up  a  considerable  distance  towards  the 
fundus.  The  method  probably  acts  partly  by  the  direct  stimulus 
caused  by  the  uterine  distension,  and  partly  by  separating  the 
membranes  from  the  uterine  wall  over  a  considerable  surface,  so 
that  the  ovum  acts  as  a  foreign  body,  and  excites  reflex   action. 


Induction  of  Premature   Labour,   Etc.     80 1 

In  some  cases,  however,  these  intra-uterine  injections  have  been 
followed  by  sudden  death.  This  is  a  result  so  extremely  unpleasant 
for  the  accoucheur,  that  the  general  use  of  the  method  has  been 
given  up,  although  it  is  probable  that,  in  very  skilled  hands,  it 
may  be  as  safe  as  others.  The  cause  of  sudden  death  is  most  likely 
the  entrance  of  air  into  opened  venous  sinuses  at  the  placental 
site.  This  appeared  to  be  demonstrated  in  one  case  at  least,  which 
occurred  in  America,  where  a  Higginson's  syringe  had  been  used 
in  the  injection  of  water  into  the  uterus  for  the  induction  of 
criminal  abortion.  After  death,  the  heart  was  found  full  of  froth, 
and  it  was  also  found,  on  testing  the  syringe,  that,  in  consequence 
of  its  not  being  air-tight,  a  considerable  quantity  of  air  would  be 
injected  with  the  water. 

If,  therefore,  this  method  should  ever  be  adopted,  an  ordinary 
syringe,  not  a  Higginson's  syringe,  should  always  be  used,  and 
great  care  should  be  taken  that  no  air  remains  in  the  tube  or  in 
the  syringe.  Seven  or  eight  ounces  of  warm  water  would  probably 
be  sufficient  to  produce  the  effect. 

Injection  of  Glycerine, — Pelzer  has  introduced  the  method 
of  injecting  slowly  from  an  ounce  to  an  ounce  and  a  half  of  aseptic 
glycerine  between  the  membranes  and  the  uterine  wall  by  means 
of  a  catheter  passed  through  the  cervix.  He  considers  that 
glycerine  acts  as  an  exciter  of  labour  in  three  ways :  (1)  by 
mechanical  separation  of  the  membranes ;  (2)  by  a  direct  irritant 
effect  on  the  uterine  mucous  membrane,  which  excites  muscular 
action  as  rectal  glycerine  injections  excite  contraction  of  the  bowel ; 
and  (3)  by  the  affinity  of  glycerine  for  water,  the  liquor  amnii  being 
drawn  through  the  membranes,  causing  more  or  less  collapse. 
This  method  has,  however,  been  abandoned  almost  entirely,  since 
it  has  been  found  that  the  intra-uterine  injection  of  glycerine  may 
be  followed  by  toxic  symptoms  such  as  hsemoglobinuria  and  the 
occurrence  of  acute  parenchymatous  nephritis.^ 

Vaginal  Tampons, — C.Braun,  of  Vienna,  introduced  the  method 
of  inducing  labour  by  means  of  a  vaginal  dilator  of  india-rubber 
distended  with  water.  This  dilator,  under  the  name  of  the 
colyeurynter ,  was  for  some  time  considerably  used  in  Germany. 
The  method  is,  however,  uncertain  as  to  time,  and  unpleasant 
to  the  patient.  In  cases  of  accidental  haemorrhage  or  placenta 
previa   tight    plugging    of    the   vagina,   combined    with    pressure 

1  Pfannenstiel,  Zcritr.  f.  Gyniik.,  1804,  No.  18,  p.  37. 
M.  51 


802 


The   Practice  of   Midwifery. 


upon  the  uterus,  has  been  found  an  effectual  means  of  starting 
labour  (see  p.  604). 

Choice  of  Method. — In   ordinary  cases,  when   time   does   not 
press,  the  best  method  is  the  introduction  of  a  bougie.     If  there  is 


Fig.  396. — Hearson's  Theemostatic  Nurse. 

Tank  of  warm  water  interposed  between  upper  and  lower  compartment  (a  and  b) 
D  D.  Slips  of  wood  supporting  cradle.  S.  Capsule  containing  a  liquid  which  boils 
at  the  temperature  at  which  it  is  desired  to  keep  the  chamber  A.  From  the  centre 
of  the  capsule  s,  a  stifi  wire  passes  out  through  the  top  of  the  apparatus,  where  it 
comes  into  contact  with  a  light  lever  V,  which  is  hinged  at  F.  From  the  free  end 
of  this  lever  hangs  a  damper  (w),  which  rests  on  the  top  of  the  chimney  under 
which  the  flame  burns.  If  the  temperature  in  the  compartment  A  rises  too  high, 
the  fluid  in  the  capsule  (s)  boils  and  expands  the  capsule,  thus  raising  the  wire 
rod,  which,  acting  on  the  lever  v,  at  once  lifts  the  damper  (w)  ofE  the  chimney, 
allowing  the  heat  from  the  flame  to  escape  by  that  outlet,  and  preventing  the 
further  heating  of  the  water.  M.  Aperture  for  entrance  of  air.  o.  Tray  contain- 
ing water.  The  centre  of  this  tray  is  raised  in  the  form  of  a  cap  (p),  which  fits 
over  the  aperture  M,  through  which  the  air  enters.  It  is  perforated  all  round 
its  sides,  so  that  the  air  jjasses  through  it  horizontally,  as  shown  by  the  arrows, 
instead  of  rising  vertically.  Another  tray  (x)  of  very  coarsely  perforated  zinc, 
somewhat  smaller  than  the  first,  is  turned  upside  down  within  it,  and  over  this  is 
fitted  the  coarse  canvas  (n),  the  edges  of  which  are  tucked  into  the  water  all 
round.  Thus  the  air  entering  is  constantly  moistened  as  well  as  heated.  R  R.  Flue, 
shaped  like  the  letter  U,  through  which  the  heated  air  from  the  flame  passes,  so  as 
to  twice  traverse  the  length  of  the  water-tank,  and  thus  keep  the  water  heated. 
In  the  top  of  the  apparatus  is  a  glass  window,  through  which  the  infant  is  kept  in 
view.  If  a  higher  temperature  than  the  boiling-point  of  the  liquid  within  the 
capsule  be  desired,  this  can  be  obtained  by  moving  the  weight  T  along  the  lever 
towards  the  end  to  which  the  damper  is  attached. 


urgent  need  to  effect  delivery  as  rapidly  as  possible,  the  membranes 
should  be  ruptured,  and  the  cervix  then  dilated  by  Champetier  de 
Eibes'  bag,  after  preliminary  use,  if  necessary,  of  mechanical 
dilators.     In  case  of  great  urgency,  the  cervix  can  be  more  rapidly 


Induction   of  Premature   Labour,   Etc.     803 

dilated    by   Bossi's    or  Frommer's    dilator,    or  vaginal  Csesarean 
section  may  be  performed. 

Care  of  the  Child, — The  rearing  of  a  premature  child  is  the 
more  difficult  the  earlier  is  the  date  of  its  birth,  and  often  is  only 
possible  when  minute  and  unremitting  care  is  expended  upon  it. 
Protection  from  cold  is  the  first  essential.  In  winter,  therefore,  the 
child  should  be  wrapped  in  cotton  wool  immediately  on  its  birth, 
and  kept  near  the  fire  in  a  warm  room. 

Hearson's  Thermostatic  Nurse  (Fig.  396). — This  is  warmed 
and  adequately  ventilated,  so  that  the  demands  upon  the  heat- 
producing  powers  of  the  baby  are  diminished  as  much  as  possible. 
The  source  of  heat  is  a  gas  jet  or  oil  lamp,  and  the  box  is  kept  at 
any  uniform  temperature  that  may  be  desired  by  an  ingenious 
automatic  arrangement.  In  general,  the  temperature  may  be  set 
at  85°  F.,  but  it  has  been  made  as  high  as  95°  without  injury  to 
the  infant.  As  time  goes  on,  it  is  gradually  lowered.  The  child 
is  kept  in  the  box  for  some  weeks,  being  taken  out  only  for  feeding 
and  washing.  It  is  generally  found  that  it  is  quiet  and  happy, 
under  the  influence  of  the  equable  warmth. 

A  very  feeble  premature  child  should  not  be  taken  up  more  often 
than  can  be  helped,  and  should  only  be  washed  every  second  or 
third  day.  It  is  quite  easy  to  keep  it  clean  by  smearing  the 
buttocks  with  lanoline  or  pure  vaseline  and  then  wi]3ing  this  off 
with  cotton  wool.  If  not  strong  enough  to  suck,  it  must  be  fed,  the 
mother's  milk  being  drawn  off  for  that  purpose  and  given  to  the 
infant  with  a  spoon  or  special  drop  feeder.  In  most  instances 
the  child  will  thrive  best  if  it  be  fed  for  the  first  ten  days  or  so  upon 
good  nursery  milk  completely  peptonised.  After  ten  to  fourteen 
days  unpeptonised  milk  is  very  gradually  and  slowly  substituted 
for  the  peptonised,  about  one  teaspoonful  at  a  time,  every  two  or 
three  days,  depending  upon  the  manner  in  which  the  child  is 
thriving,  until  at  length  only  the  former  is  being  given.  In  this 
way  it  is  usually  possible  to  rear  without  undue  difficulty  even  the 
most  premature  and  delicate  babies. 

Induction  of  Artificial  Abortion. 

Indications  for  Operation.— Induction  of  artificial  abortion  is 
called  for  in  two  classes  of  cases.  (1.)  When  the  dehvery  of  a  viable 
child  through  the  natural  passages  is  impossible,  and  the  induction 
of  abortion  offers  any  advantage  to  the  mother  as  compared  with 

51—2 


8o4  The  Practice  of   Midwifery. 

delivery  at  full  term.  (2.)  When  the  mother's  life  is  materially 
endangered  by  the  continuance  of  pregnancy,  while  cutting  short 
the  pregnancy  is  likely  to  save  it. 

Hence  in  all  cases  in  which  the  pelvis  is  so  obstructed  by  deformity 
or  the  presence  of  tumours  that  delivery  even  by  craniotomy  is 
likely  to  be  impossible,  or  even  very  difficult  and  dangerous,  abortion 
may  be  induced  should  the  alternative  of  Cfesarean  section  at  term 
not  be  accepted  by  the  mother. 

The  various  conditions  endangering  the  mother's  life,  and  on 
that  account  calling  for  the  induction  of  abortion,  have  been 
considered  among  the  diseases  of  i^regnancy.  That  which  most 
frequently  raises  the  question  is  severe  vomiting  in  pregnancy. 
It  is  only  very  exceptionally,  however,  that  life  is  actually 
endangered,  and  the  physician  has  often  to  resist  the  desire  of 
the  patient,  who  is  wearied  and  exhausted  by  the  malady.  The 
other  conditions  which  may  call  for  artificial  abortion  are  albumi- 
nuria, jaundice,  eclampsia,  uterine  haemorrhage,  hydramnios, 
chorea,  pernicious  anaemia,  leucaemia,  and  diseases  of  heart  or 
lungs.  Induction  of  abortion  has  been  performed  in  chronic 
.phthisis  ;  but  the  general  opinion  is  that,  in  general,  the  effect  upon 
the  course  of  the  disease  is  so  doubtful  that  the  operation  is  not 
justified.  The  case  in  which  there  need  be  least  hesitation  in 
inducing  abortion  is  that  of  uterine  haemorrhage  sufficient  to  cause 
serious  symptoms,  for  there  is  then  very  little  chance  that  the 
ovum  can  ultimately  be  saved  in  any  case.  In  threatened  or 
incipient  insanity  a  delicate  ethical  question  may  arise,  and  each 
case  must  be  judged  on  its  own  merits.  But  it  will  generally  be 
held  that  the  sacrifice  of  the  child  is  justifiable,  if  there  is  very 
strong  ground  for  believing  that  the  mother's  reason  will  thereby 
be  saved.  In  most  cases,  however,  the  interference  itself  is  as 
likely  to  be  injurious  to  the  mental  condition  as  the  continuance  of 
pregnancy. 

It  should  be  an  invariable  rule  that  artificial  abortion  should 
never  be  induced  without  a  preliminary  consultation.  This  is 
necessary  for  the  protection  of  the  practitioner  himself  against  any 
possible  imputation  of  an  improper  motive. 

Choice  of  Time. — If  there  is  a  choice  of  time  for  the  induction 
of  abortion,  there  are  some  advantages  in  undertaking  the  opera- 
tion within  the  first  eight  or  ten  weeks  of  pregnancy,  for  then  the 
ovum  may  be  ex^Delled  unbroken,  and  the  abortion  is  a  less  serious 
matter.  If,  however,  the  pregnancy  has  passed  beyond  the  tenth 
week,   it   is   better,   when   circumstances   permit,   to   allow  it   to 


Induction   of   Premature  Labour,   Etc.     805 

continue  as  far  on  as  possible  toward  the  twentieth  week,  that  the 
placenta  may  become  more  readily  separable,  and  the  membranes 
easier  to  puncture. 

Mode  of  operating. — Within  the  first  ten  weeks  of  pregnancy, 
the  best  method  is  to  dilate  the  cervix  with  a  laminaria  tent,  careful 
antiseptic  precautions  being  taken,  and  the  tent  being  anointed 
with  an  antiseptic  lubricant,  as  lanocyllin,  iodoform  in  vaseline 
(1  in  8),  or  salicylic  cream.  Such  dilatation  will  generally  call  out 
uterine  action,  but,  if  not,  the  finger  may  be  passed  up  through  the 
dilated  cervix,  and  the  ovum  punctured  with  a  sound.  Up  to  the 
end  of  the  third  month,  or  even  later,  this  will  often  prove  difficult, 
as  the  bag  of  membranes  is  lax,  and  does  not  fill  the  cavity  of  the 
uterus.  In  this  case,  a  pair  of  forceps  may  be  passed  up  into  the 
uterus,  guided  by  the  finger,  and  a  piece  of  the  membranes  torn 
away,  letting  out  the  liquor  amnii.  If  any  considerable  haemor- 
rhage is  thus  produced,  dilatation  of  the  cervix  should  be  comj)leted 
with  Hegar's  dilators,  and  the  uterus  at  once  evacuated. 

Another  method  which  may  be  employed  instead  of  a  tent  is  to 
plug  the  vagina  and  cervical  canal  with  a  strip  of  iodoform  gauze. 

In  the  later  months  it  is  generally  better  to  puncture  the  mem- 
branes at  once,  since  the  ovum  is  not  likely  to  be  expelled  intact. 
For  this  purpose  a  rather  narrow-pointed  uterine  sound  may  be 
used.  The  point  is  passed  up  to  the  internal  os,  and  directed  as 
perpendicularly  as  possible  to  the  surface  of  the  ovum.  It  is  then 
pushed  through  the  membranes  by  a  rather  sudden  movement. 
In  the  later  months  of  pregnancy  it  is  always  possible  to  do  this. 
But  up  to  about  four  months,  if  the  membranes  do  not  fill  the 
entire  uterus,  and  are  lax,  as  well  as  tough,  it  may  be  impossible, 
until  the  cervix  has  been  dilated. 

If  it  is  important  to  evacuate  the  uterus  quickly,  as  in  cases 
where  there  is  much  haemorrhage,  or  an  offensive  discharge,  the 
cervix  may  be  rapidly  dilated  under  anaesthesia,  by  means  of 
Hegar's  dilators  or  Bossi's  dilator,  and  the  contents  removed  with 
the  finger,  aided,  if  necessary,  by  a  pair  of  ovum  forceps.  The 
artificial  dilatation  of  the  cervix  and  the  emptying  of  the  uterus  at 
about  the  fourth  or  fifth  month  of  pregnancy  is  often  a  very  difficult 
matter,  and  for  this  reason  some  writers  favour  the  performance 
of  vaginal  Cacsarean  section  in  all  cases  where  there  is  any 
urgency. 


Chapter  XXXII. 

EXTRACTION  OF  THE  FOETUS  IN  PELVIC 
PRESENTATIONS. 

It  has  already  been  explained  (see  p.  359)  that,  in  the  manage- 
ment of  pelvic  presentations,  the  most  important  point  is  to  avoid 
premature  interference  with  nature  ;  and  that  artificial  aid,  beyond 
that  afforded  by  external  pressure  upon  the  fundus  uteri,  is  rarely 
required  before  the  stage  at  which  the  arms  have  escaped  and  the 
head  alone  is  still  retained  within  the  vulva,  lying,  no  longer  in  the 
body  of  the  uterus,  but  in  the  vagina  and  distended  cervix.  The 
mode  of  extracting  the  head  under  these  circumstances  has  also 
ah'eady  been  described  (see  p.  361). 


Causes  of  Impaction  in  Breech  Presentation.  —  Undue 
protraction  of  labour  may,  however,  occur,  and  interference  on 
that  account  be  called  for  at  an  earlier  stage.  This  may  result 
in  breech  presentations — (1),  from  disproportion  between  the 
foetus  and  the  pelvis  ;  (2),  from  rigidity  of  the  soft  parts,  such 
as  is  common  in  primiparfe,  associated  with  more  or  less  uterine 
inertia  ;  and  (3),  from  the  attitude  of  the  foetus.  In  presentations 
of  a  foot,  or  both  feet,  the  first  or  second  of  the  causes  may  be  in 
operation. 

In  general,  the  limbs  of  the  foetus  in  breech  presentations  are  in 
the  same  general  condition  of  flexion  as  in  head  presentations  (see 
Fig.  217,  p.  3-16),  and  the  feet  are  close  to  the  breech.  Sometimes, 
however,  the  legs  are  extended  upon  the  thighs,  so  that  the  feet  are 
above  the  shoulders,  and  the  toes  close  to  the  head  (see  Fig.  218, 
p.  347).  In  this  case  the  whole  foetus  may  form  a  wedge  with  its 
base  uppermost,  the  dimensions  of  that  base,  formed  by  the  head 
and  feet  together,  being  too  great  for  the  corresponding  diameters 
of  the  pelvis.  The  advance  of  the  foetus  is  thereby  arrested.  Even 
that  part  of  the  wedge  formed  by  the  shoulders  and  arms,  with  the 
legs  added  (see  Fig.  218),  may  be  too  large  to  enter  the  brim,  and 
progress  is  then  arrested  earlier.  If  the  trunk  of  the  foetus  is 
extended,  the  legs  are  not  long  enough  to  allow  the  feet  to  reach 
up  to  the  level  of  the  head.  For  the  formation  of  the  obstructing 
wedge,  it  is  necessary  that  there  should  be  flexion  of  the  foetal 


Extraction  of  Foetus  in  Pelvic  Presentations.    807 

pelvis  upon  the  trunk,  owing  to  flexion  of  the  lumbar  and  lower 
dorsal  spine.  Hence,  when  one  leg  is  descending  in  advance, 
having  either  presented  originally  or  been  brought  down  artificially, 
the  obstructing  wedge  is  never  formed,  and  it  is  not  necessary  to 
bring  down  the  second  leg  in  order  to  break  it  up.  For,  in  this 
case,  the  position  of  the  thigh  in  the  genital  canal  causes  some 
extension  of  the  pelvis  upon  the  trunk. 

There  is  also  another  mode  in  which  extension  of  the  legs  causes 
impaction,  or  arrest  of  progress,  in  breech  presentations.  When 
the  extended  legs  lie  on  each  side  of  the  trunk,  they  form,  as  it 
were,  splints,  keeping  the  trunk  straight,  and  preventing  that 
lateral  flexion  of  the  breech  which  is  essential  to  its  escape  under 
the  pubic  arch.  This  cause  comes  into  operation  at  an  earlier  stage 
than  that  at  which  the  wedge  formed  by  the  legs  with  shoulders 
or  head  would  be  obstructed  by  the  pelvis.  If,  however,  the  legs 
lie  at  the  front  of  the  trunk,  not  at  the  sides,  they  do  not  altogether 
prevent  the  lateral  flexion,  although  they  must  somewhat  impede 
it,  the  lateral  flexion  of  the  breech  to  one  side  implying  a  deflection 
of  the  feet  toward  the  opposite  side. 

It  is  probable  that  the  position  of  complete  extension  of  the  legs 
upon  the  thighs  is  rarely  an  original  one.  The  limbs  of  the 
embryo,  as  it  grows,  are  naturally  in  a  position  of  general  flexion, 
just  as  the  leaves  are  folded  in  a  bud.  But  some  degree  of  exten- 
sion may  arise  through  foetal  movements,  and  the  legs  may  remain 
fixed  in  the  extended  position  if  the  liquor  amnii  escapes  at  the 
moment  when  extension  exists.  It  has  already  been  explained 
that  the  comparative  want  of  space  in  the  lower  segment  of  the 
uterus  favours  a  partial  extension  of  the  legs  during  pregnancy. 
Assuming  that,  at  an  early  stage  of  labour,  there  is  a  partial 
extension,  like  that  of  the  left  leg  in  Fig.  217  (p.  346),  this  may 
be  increased  as  the  breech  descends,  the  legs  being  retarded  by 
friction  against  the  uterine  wall,  and  thus  the  complete  extension 
may  eventually  be  reached. 

In  a  few  cases,  the  extended  position  of  the  legs  is  inferred  to 
be  primary,  because  the  legs  naturally  take  that  position  after 
the  birth  of  the  child,  and  spring  back  into  it  when  flexed  by  the 
hand. 

Allowance  has  to  be  made  for  the  fact  that,  in  foot  or  breech 
presentations,  labour  is  generally  more  lingering  than  in  vertex 
presentations,  the  half-breech  or  breech  not  causing  so  great  reflex 
stimulus  to  the  pains  by  its  pressure  as  the  head.  But  interference 
becomes  necessary  if  the  mother  begins  to  show  the  constitutional 
effects  of  protracted  labour  (see  p.  620),  or  if  there  is  evidence  of 


8o8  The   Practice  of   Midwifery. 

impending  asphyxia  of  the  foetus.  Such  evidence  may  consist  of 
increased  slowness  and  feebleness  of  the  foetal  heart,  or,  if  the 
breech  has  already  passed  the  vulva,  of  attempted  inspiratory 
movements.  After  version,  early  extraction  is  more  frequently 
desirable  or  necessary  than  in  primary  presentations  of  the  foot ; 
first,  because  the  life  of  the  foetus  has  often  already  been  imperilled 
by  the  condition  which  called  for  version ;  secondly,  because  the 
version  may  have  interfered  with  the  natural  position  of  flexion  of 
the  arms  ;  and,  thirdly,  because  some  pelvic  contraction  often  exists 
in  cases  of  shoulder  presentation. 

The  delivery  of  the  foetus  in  pelvic  presentations  consists  of  three 
stages: — (1),  delivery  of  the  trunk;  (2),  liberation  of  the  arms; 
(3),  extraction  of  the  head.  The  various  means  of  delivering  the 
trunk  will  first  be  considered. 

Extraction  by  the  Feet. — When  one  or  both  feet  are  already 
presenting,  traction  on  the  leg  is  the  mode  of  acceleration  to  be 
adopted.  The  patient,  as  a  rule,  may  be  kept  in  the  ordinary  left 
lateral  position.  But,  for  the  final  stage  of  extraction,  there  is  a 
certain  advantage  in  placing  the  patient  in  the  dorsal  position, 
across  the  bed,  the  buttocks  overhanging  the  edge  of  the  bed,  and 
the  feet  rested  on  two  chairs.  The  operator  stands  between  the 
knees.  This  position  allows  an  assistant  to  press  more  effectively 
upon  the  fundus,  and  the  child's  trunk  to  be  more  easily  carried 
forward  in  front  of  the  pubes. 

It  is  most  important  that  in  the  delivery  of  the  foetus  in  pelvic 
presentations  the  cervix  should  be  fully  dilated,  as  if  any  delay  from 
an  undilated  cervix  occurs  in  the  delivery  of  the  after-coming  head, 
the  child  will  almost  certainly  be  still-born. 

If  the  foot  is  still  in  the  vagina,  the  operator  seizes  it  by  placing 
the  index  and  middle  fingers  in  front  of  and  behind  the  leg,  just 
above  the  foot,  and  draws  it  outside.  If  necessary,  the  thumb  may 
assist  in  grasping  it.  As  soon  as  the  foot  is  outside  the  vulva,  it  is 
grasped  with  the  aid  of  a  napkin.  As  the  leg  descends,  the  grasp 
is  shifted  higher,  so  that  the  leg  is  held  as  close  as  possible  to  the 
vulva.  If  pains  are  fairly  frequent,  traction  should  be  made 
during  the  pains  only.  In  the  absence  of  sufficient  pains,  the 
traction  should  be  at  intervals,  like  those  of  ordinary  pains.  With 
each  traction  firm  pressure  should  be  made  upon  the  fundus.  The 
object  of  this  is  not  only  to  gain  additional  force,  but  to  prevent 
extension  of  the  arms  above  the  head,  both  by  direct  pressure,  and 
by  stimulating  the  uterus  to  contract. 

Until  the  half -breech  is  resting  upon  the  perineum,  the  direction 


Extraction  of  Foetus  in  Pelvic  Presentations.    809 

of  traction  should  be  as  far  backward  as  the  perineum  will  allow. 
This  direction  of  traction  will  nevertheless  be  inclined  forward  in 
reference  to  the  axis  of  the  brim  and  that  of  the  upper  half  of  the 
pelvic  cavity.  It  will  therefore  assist  in  rotating  the  presenting 
thigh  under  the  pubic  arch,  and  there  is  no  necessity  for  using  any 
other  means  to  promote  this  rotation.  As  soon  as  the  half-breech 
begins  to  distend  the  perineum,  the  direction  of  traction  must  be 
shifted  rather  rapidly  forward.  At  this  stage  additional  force  may 
be  gained,  if  desired,  by  hooking  the  index  finger  of  the  left  hand 
in  the  flexure  of  the  other  thigh. 

If  both  feet  present,  they  may  both  be  brought  down  outside  the 
vulva,  and  grasped  together  for  traction.  If,  however,  the  anterior 
hip  does  not  rotate  readily  under  the  pubic  arch,  rotation  will  be 
promoted  if  the  traction  is  made  mainly  upon  the  anterior  leg. 
When  both  legs  come  down,  it  is  sometimes  found  that  the  funis 
passes  between  the  legs,  and  up  the  back  to  the  placenta.  The 
child  is  then  said  to  ride  upon  the  funis.  In  this  case  an  attempt 
should  be  made  to  draw  down  as  much  as  possible  of  the  funis  and 
slip  the  loop  over  one  leg.  If  this  attempt  fails,  the  funis  should 
be  tied  and  divided,  and  the  child  extracted  as  quickly  as  possible. 

Bringing  Down  the  Leg  in  Breech  Presentation. — If  accelera- 
tion of  labour  is  called  for  in  breech  presentation,  the  best  treat- 
ment is  to  bring  down  one  leg,  and  then  proceed  to  extract  by 
that  leg  in  the  manner  just  described.  When  the  child  is  in  its 
ordinary  attitude,  it  is  easy  to  accomplish  this,  even  when  the 
breech  has  descended  low  into  the  vagina,  for  the  feet  will  be  found 
close  to  the  breech.  In  general  it  is  better  to  give  an  anaesthetic. 
If  the  patient  is  on  her  left  side,  the  right  hand  may  be  used ;  if 
she  is  in  the  dorsal  position,  the  hand  should  be  chosen  so  that  its 
palm  corresponds  to  the  abdomen  of  the  foetus.  The  foot  of  the 
anterior  leg  should  be  taken  if  possible.  If,  however,  the  breech 
is  still  high  up,  it  is  not  of  much  consequence  which  is  taken,  for 
the  leg  which  is  brought  down  will  rotate  forward  under  the  pubic 
arch  as  the  foetus  descends. 

If  the  legs  are  extended  upon  the  thighs,  as  shown  in  Fig.  218 
(p.  347),  the  operation  is  much  more  difficult.  In  order  to  seize 
the  foot,  the  hand  must  ))e  passed  up  higher  into  the  uterus  than 
is  ever  necessary  in  version,  and  even  when  the  foot  is  seized, 
there  may  be  much  difficulty  in  flexing  the  leg,  owing  to  the 
resistance  of  the  uterine  wall.  The  operation  is  therefore  often 
more  difficult  tlian  any  ordinary  case  of  version. 

The  patient  should  be  placed  under  the  influence  of  chloroform 


8io 


The   Practice  of   Midwifery. 


to  the  full  surgical  degree,  so  as  to  secure  the  greatest  possible 
relaxation  of  the  uterus.  In  general,  as  in  the  case  of  version, 
it  is  preferable  to  place  the  patient  on  her  left  side,  and  introduce 
the  right  hand  and  arm.  The  hand  must  be  cautiously  passed  up 
into  the  uterus,  in  the  intervals  of  pains,  as  for  performance  of 
internal  version.  The  left  hand  makes  counter-pressure  upon 
the  fundus.  Adequate  counter-pressure  must  always  be  made  upon 
the  fundus  of  the  uterus  during  the  delivery  of  the  child  in  pelvic 


Fig-.  397. — Pinard's  manoeuvre. 


presentations  so  as  to  minimise  as  much  as  possible  the  likelihood 
of  the  head  or  arms  becoming  extended.  The  hand  must  be  passed 
on  quite  to  the  fundus  to  reach  the  instep  or  foot.  It  is  guided  to 
the  anterior  foot  by  tracing  up  the  leg  from  the  breech.  It  is 
useless  to  attempt  to  flex  the  leg  directly  forward.  The  foot 
must  be  carried  toward  the  opposite  side  of  the  foetus.  Thus  the 
right  foot  should  be  swept  across  toward  the  left  side  of  the  chest. 
The  effect  of  this  is  to  turn  the  knee  outward  and  evert  the  thigh. 
There  is  then  room  for  the  leg  in  a  transverse  position,  lying  flat 
against  the  uterine  wall. 


Extraction  of  Foetus  in  Pelvic  Presentations.    8ii 

Pinard's  manoeuvre  is  often  very  useful  in  these  cases  ;  it  consists 
in  making  pressure  on  the  flexor  aspect  of  the  knee  joint  with  two 
fingers ;  this  will  often  cause  some  flexion  of  the  joint,  with  the 
result  that  the  foot  is  brought  nearer  and  can  be  more  readily 
seized  (Fig.  397). 

The  operator  is  to  flex  the  leg  and  draw  it  across,  by  placing 
the  index  and  middle  fingers  upon  the  instep.  It  is  not  generally 
necessary  to  use  the  thumb  to  grasp  the  foot.  If  the  thumb  is 
used,  the  closed  hand  occupies  more  space  in  the  uterus. 

Some  eminent  authorities  have  considered  that  the  operation  is 
only  possible  before  the  breech  has  descended  into  the  pelvis,  and 
becomes  impossible  or  dangerous  when  the  breech  is  low  down. 
There  is  room,  however,  for  the  leg  or  thigh  to  lie  transversely 
across  the  pelvis,  unless  there  is  very  great  general  contraction, 
and  also  across  the  dilated  vagina.  The  chief  difficulty  is  to  pass 
the  hand  past  the  breech,  when  the  breech  is  close  to  the  perineum. 
Great  gentleness  and  caution  are  required  at  this  stage. 

I  have  always  found  it  possible  to  bring  down  a  foot  in  the 
manner  here  described,  and  have  never  had  occasion  to  resort  to 
any  of  the  means  recommended  by  many  eminent  authorities  for 
the  treatment  of  impacted  breech  presentations,  such  as  the  use  of 
the  soft  fillet,  or  blunt  hook,  or  the  application  of  forceps  to  the 
breech  ;  nor  were  such  means  ever  found  necessary  in  389  breech 
presentations  occurring  in  23,591  deliveries  in  the  Guy's  Hospital 
Charity.  The  operator  might,  however,  find  it  impossible  to  secure 
a  leg,  if  the  uterus  were  very  closely  contracted  around  the  child 
after  long  escape  of  the  liquor  amnii,  especially  if  the  breech  were 
close  to  the  perineum,  or  there  were  great  general  contraction 
of  the  pelvis. 

Digital  Traction, — The  plan  of  digital  traction  in  breech  pre- 
sentation is  one  which  may  be  tried,  if  labour  is  arrested,  when  the 
breech  is  close  to  the  perineum,  before  recourse  is  had  to  the  plan 
of  bringing  down  a  foot.  The  index  finger  is  hooked  in  the  flexure 
of  the  anterior  groin  and  traction  made  therewith.  It  may  be  of 
service  to  make  the  traction  alternately  on  the  anterior  and 
posterior  groin,  and  so  get  the  benefit  of  leverage.  If  the  vaginal 
space  allows,  the  right  index  finger  may  be  hooked  into  the  anterior 
groin,  and  the  left  into  the  posterior. 

The  Soft  Fillet. — Traction  by  means  of  a  soft  fillet  is  the  best 
means  to  employ  in  the  case  of  failure  in  the  attempt  to  bring  down 
a  leg.     The  fillet  is  sometimes  passed  over  one  thigh  only.     In 


8l2 


The  Practice  of   Midwifery. 


such  case  the  anterior  thigh  should  be  chosen  if  possible.  If  the 
fillet  can  be  passed  across  both  thighs,  the  pressure  is  more  dis- 
tributed, and  is  less  likely  to  injure  the  skin  or  soft  parts  of  the 
groin.  It  is  better  still,  although  more  difficult,  to  pass  the  fillet 
round  the  child's  pelvis  in  the  following  way.  A  soft  sterilised 
handkerchief  or  bandage  may  be  used  for 
the  fillet ;  a  knot  is  to  be  tied  at  two 
opposite  corners  or  ends.  By  means  of 
the  forejfinger  the  corner  is  to  be  passed 
from  without  inwards  over  the  flexure  of 
the  groin  till  the  knot  can  be  reached 
between  the  thighs  and  drawn  down.  In 
the  same  way  the  opposite  end  of  the  fillet 
is  to  be  passed  from  within  outwards  over 
the  other  thigh.  The  centre  of  the  fillet 
is  then  slipped  up  over  the  buttocks  till  it 
surrounds  the  sacrum,  and  traction  is  made 
by  the  ends.  In  this  way  the  pressure  is 
distributed  over  both  groins  and  the  circum- 
ference of  the  pelvis.  If  the  fillet  is  passed 
over  one  or  both  thighs  only,  care  must  be 
taken,  if  the  abdomen  looks  forward,  that 
it  does  not  slip  up  from  the  groin  to  the 
thigh,  and  so  cause  fracture  of  the  femur. 

In  place  of  the  handkerchief  a  piece  of 
thick- walled  india-rubber  tubing  about  the 
size  of  the  little  finger  may  be  used.  A 
strong  piece  of  tape  is  passed  through  the 
tube  and  sewn  to  the  tube  at  each  end, 
the  ends  of  the  tape  projecting  beyond  the 
tube.  The  knotted  ends  of  the  tape  are 
then  passed  over  the  flexures  of  the  groins 
from  without  inward  as  before. 

If  the  fillet  cannot  be  passed  over  the 
thigh  by  the  index  finger  a  large  gum-elastic 
catheter,  with  stylet,  may  be  bent  to  a  suit- 
able shape,  resembling  that  of  the  blunt  hook,  and  passed  from 
without  inward  over  the  thigh,  having  a  tape  attached  to  its 
extremity.  By  means  of  the  tape,  the  fillet  can  then  be  drawn  into 
position.  A  special  instrument,  or  porte-fiUet,  has  been  made  for 
this  purpose,  on  the  principle  of  Bellocq's  sound,  used  for  plugging 
the  iDOsterior  nares,  but  having  a  curve  like  the  blunt  hook.  A 
long  piece  of  whalebone  runs  through  the  central  canal. 


Fig.  398.— The  blunt  hook. 


Extraction  of  Foetus  in  Pelvic  Presentations.    813 

Traction  by  means  of  the  soft  fillet  generally  so  far  breaks  up 
the  opposing  wedge  as  to  allow  the  foetus  to  pass,  unless  there  is 
great  disproportion  between  foetus  and  pelvis.  For  the  traction 
on  the  flexures  of  the  groins  diminishes  the  flexion  of  the  foetal 
pelvis  upon  the  trunk,  and  by  this  means  brings  the  feet  below 
the  level  of  the  head. 

The  Blunt  Hook.— The  blunt  hook  is  an  instrument  con- 
structed expressly  for  extraction  in  breech  presentation  (Fig.  398, 
p.  812).  It  is  not,  however,  desirable  to  use  it,  in  the  case  of  a 
living  child,  unless  all  other  means  have  failed,  on  account  of  the 
injury  which  it  is  liable  to  do  to  the  skin  and  soft  parts  of  the  groin. 
The  instrument  is  generally  made  of  steel,  and  the  diameter  of  the 
semicircular  curve  forming  a  hook  is  about  two  inches.  The 
likelihood  of  injuring  the  groin  will  be  less,  if,  at  the  time  of  use, 
a  piece  of  sterilised  india-rubber  tubing,  jStting  the  hook  closely, 
is  slipped  over  it.     The  tubing  should  be  new  for  the  occasion. 

It  is  better  to  place  the  hook  over  the  anterior  thigh.  It  is 
passed  up,  lying  flat  against  the  thigh,  the  point  directed  towards 
the  front  of  the  foetus.  When  high  enough  the  point  is  turned 
inward,  and  passed  over  the  flexure  of  the  groin.  Care  must  be 
taken  to  feel  the  point  lying  clear  between  the  thighs,  before 
traction  is  made.  When  the  foetus  is  dead,  the  blunt  hook  is  a 
good  means  of  traction,  and  will  generally  succeed  in  sufficiently 
decomposing  the  obstructing  wedge,  by  bringing  the  feet  below 
the  level  of  the  head.  It  can  rarely,  however,  be  certainly  known 
that  the  child  is  dead,  unless  the  funis  is  within  reach. 

Forceps. — The  application  of  forceps  to  the  breech  has  been 
recommended  by  some  eminent  authorities.  Forceps  specially 
adapted  for  this  purpose  have  even  been  devised,  and  have  been 
distinguished  by  the  title  of  "retroceps."  Forceps  of  any  form 
are,  however,  unsuitable  for  holding  the  breech.  The  tips  of  the 
blades  cannot  be  approximated  without  risk  of  injury  to  the  foetus. 
If  they  remain  divergent,  there  is  a  very  wide  sjjace  between  the 
centres  of  the  blades.  In  consequence  of  this,  not  only  are  the 
forceps  apt  to  slip  off,  but  injury  may  be  done  to  the  maternal 
tissues.  Lusk,  however,  speaks  highly  of  the  application  of 
Tarnier's  axis-traction  forceps  to  the  breech,  one  blade  being 
applied  over  each  thigh  of  the  foetus.^ 

If  extraction  Ijy  forceps  is  attempted  at  all,  it  should  only  be 
after  the  breech  has  descended  in  the  pelvis.     If  the  breech  has 

1  The  Science  and  Art  of  Midwifery,  2nd  ed.,  p.  380. 


8i4 


The   Practice  of   Midwifery. 


rotated,  one  blade  should  be  applied  over  the  sacrum,  the  other 
over  the  anterior  surface  of  one  thigh,  care  being  taken  not  to 
injure  the  genitals  of  a  male.  If  the  breech  has  not  rotated,  it  is 
recommended  to  apply  the  blades  over  the  lateral  surfaces  of  the 
thighs.  The  mode  in  which  they  should  seize  the  foetus  is  shown 
in  Fig.  399. 

Bringing  Down  the  Second  Leg. — If  the  child  is  dead,  and 
extraction  is  difficult  on  account  of  disproportion  between  foetus 
and  pelvis,  it  is  desirable  to  bring  down  the  second  leg,  as  there  is 


Fig.  399. — Axis-traction  forceps  applied  to  the  breech. 

then  no  object  in  keeping  the  half -breech  as  a  dilator  for  the  soft 
IDarts.  In  such  cases,  the  cephalotribe,  applied  over  the  pelvis ;  or 
the  cranioclast,  the  male  blade  being  passed  into  the  rectum  and  the 
female  blade  applied  over  the  sacrum,  will  afford,  if  necessary,  a  very 
powerful  hold  for  traction.  Both  legs  should  be  brought  down,  if 
possible,  before  its  application.  The  crochet,  hooked  over  the 
symphj'sis  pubis,  may  also  be  used  in  conjunction  with  traction  on 
the  legs.  If  there  is  any  morbid  distension  of  the  abdomen 
perforation  of  it  may  be  required. 


Extraction  of  Foetus  in  Pelvic  Presentations.    815 

Liberation  of  the  Arms. — The  second  stage  in  extraction  consists 
in  the  liberation  of  the  arms.  When  it  has  been  necessary  to 
accelerate  labour  by  traction,  the  arms  are  retarded  by  friction 
against  the  genital  canal,  and  generally  become  more  or  less  extended 
by  the  side  of  the  head,  instead  of  lying  folded  across  the  chest  as 
shown  in  Fig.  217  (p.  346).  They  then  do  not  slip  out  from  the 
vulva  before  the  shoulders  under  the  influence  of  the  natural  force, 
but  have  to  be  released  artificially. 


Fig.  400. — The  manner  in  which  the  pelvis  of  the  child  should  be  grasped 
by  the  two  hands. 


When  the  legs  of  the  foetus  have  escaj^ed,  the  pelvis  should  be 
grasped  in  two  hands,  and  used  for  traction.  Traction  should 
still  be  made  with  the  pains  if  possible,  and  should  be  assisted  by 
pressure  upon  the  fundus  uteri.  As  soon  as  the  funis  can  be 
reached,  a  loop  of  it  should  be  drawn  down,  as  in  normal  cases  of 
pelvic  presentation,  to  prevent  its  being  put  upon  the  stretch,  and 
should  be  placed  opposite  one  sacro-iliac  articulation,  where  it  is 
least  exposed  to  pressure.  Traction  should  be  continued  until  the 
shoulder-blades  begin  to  reach  the  vulva;  then  is  the  time  for 
releasing  the  arms. 


8i6 


The  Practice  of   Midwifery. 


In  easy  cases,  when  the  arms  are  only  shghtly  extended,  the 
anterior  arm  should  be  released  first,  but,  m  difficult  cases,  always 
the  posterior.  For,  if  the  anterior  arm  is  below  the  brim,  it  will 
be  very  close  to  the  vulval  outlet,  and  can  be  easily  hooked  by  the 
finger.  If,  however,  one  or  both  arms  are  partly  above  the  brim, 
the  posterior  is  the  easier  to  seize.  For  as  the  trunk  descends 
in  the  direction  of  the  pelvic  outlet,  the  posterior  shoulder  is 
necessarily  lower  than  the  anterior  in  reference  to  the  plane  of  the 
brim.     There  is  also  more  room  posteriorly  for  the  hand  to  be 


Fig.  401. — Bringing  down  anterior  arm  when  extended. 

passed  up  to  reach  it.  For  release  of  the  posterior  arm,  the  body 
of  the  child  should  be  held  as  far  forward  as  possible  in  front  of  the 
pubes.  The  patient  being  in  the  left  lateral  position,  the  fingers  of 
the  left  hand  should  be  introduced. 

If  the  extension  of  the  arms  is  only  moderate,  the  elbows  will  still 
lie  in  front  of  the  chest,  below  the  head,  and  the  release  of  the  arms 
is  then  easy.  Four  fingers  of  the  left  hand  are  passed  within  the 
vulva,  lying  flat  against  the  shoulder  (Fig.  401).  The  fingers  are 
run  along  the  arm  till  the  elbow  is  reached,  and  then  the  index  and 
middle  fingers  draw  the  elbow  downward  and  forward  across  the 
chest.     Care  must  be  taken  that  the  fingers  quite  reach  the  elbow, 


Extraction  of  Foetus  in  Pelvic  Presentations.    817 

and  do  not  make  the  pressure  upon  the  middle  of  the  humerus  ; 
otherwise  the  humerus  is  hkely  to  be  broken. 

For  release  of  the  anterior  arm,  the  body  of  the  child  is  held  as 
far  backward  as  possible  ;  and  the  fingers  of  the  right  hand  are 
introduced,  and  release  the  arm  in  a  similar  way.  If  the  patient 
is  in  the  dorsal  position,  that  hand  may  be  introduced  the  palm  of 
which  corresponds  to  the  abdomen  of  the  child,  for  liberation  of 
each  arm. 

Liberation  of  the  Arms  when  much  Extended. — Sometimes  the  arms 
are  found  completely  extended  by  the  side  of  the  head.  They  may 
then  become  jammed  with  the  head  in  the  pelvic  brim,  especially 
if  there  is  disproportion  between  the  foetus  and  pelvis.  Liberation  is 
then  much  more  difficult,  both  on  account  of  the  fixation  in  the  brim, 
and  on  account  of  the  difficulty  of  reaching  as  high  as  the  elbow. 

Sometimes  one  arm  is  not  merely  extended  beside  the  head,  but 
displaced  somewhat  behind  it,  and  then  the  difficulty  is  greater 
still.  This  position  is  due  to  a  rotation  of  the  trunk  in  its  descent, 
in  which  the  arm  has  been  left  behind.  The  remedy  is  to  rotate  the 
trunk  back  again  in  the  opposite  direction  and  so  bring  the  arm 
across  the  face.  The  same  proceeding  will  facilitate  the  liberation 
of  the  arm  even  if  only  extended  by  the  side  of  the  head.  The 
posterior  arm  is  to  be  liberated  first  as  in  the  former  case.  The 
trunk  of  the  foetus  is,  therefore,  to  be  grasped  with  two  hands  and 
turned  in  such  a  way  as  to  rotate  the  posterior  shoulder  towards  the 
back  of  the  foetus.  The  fingers  must  then  be  passed  quite  up  to  the 
elbow,  and  the  elbow  must  be  drawn  downwards  and  across  the  face  of 
the  foetus  towards  the  opposite  side. 

"When  the  anterior  arm  is  extended  above  the  brim,  it  is  difficult 
to  reach  the  elbow,  the  foetus  being  tightly  pressed  against  the 
symphysis  pubis.  To  overcome  this  difficulty,  the  trunk  of  the 
foetus  should  .be  rotated,  so  as  not  merely  to  reverse  the  former 
rotation,  but  to  carry  the  anterior  shoulder  backward  to  the  side 
or  posterior  part  of  the  pelvis,  and  so  convert  it  into  the  posterior 
shoulder.  The  arm  is  then  drawn  across  the  face,  and  is  in  a 
position  more  easily  accessible.  The  release  of  the  arm,  originally 
posterior,  will  generally  allow  the  foetus  to  descend  lower.  The 
trunk  should,  therefore,  be  drawn  down  as  much  as  possible. 
The  best  mode  of  rotating  the  shoulders  is  to  make  use  of  the 
released  posterior  arm  and  draw  it  forward  across  the  chest 
toward  the  symphysis  pubis.  Thus,  in  a  position  like  that  shown 
in  Fig.  401  (p.  816),  the  left  arm  should  be  drawn  forward  across 
the  chest  on  the  left  side  of  the  mother,  so  as  to  bring  the  left 
shoulder  towards  the  symphysis  pubis. 

M.  52 


8i8 


The  Practice  of   Midwifery. 


If  the  patient  is  on  the  left  side,  the  right  hand  may  be  used  for 
the  release  of  both  arms,  provided  that  the  anterior  shoulder  is 
thus  drawn  backward.  If  she  is  in  a  dorsal  position,  the  hand 
whose  palm  corresponds  to  the  abdomen  of  the  foetus  should  be 
used  for  the  posterior  arm,  the  other  hand  for  the  anterior  arm, 
after  the  shoulder  has  been  rotated  backward. 

If  the  child  descends  with  the  abdomen  looking  directly  forward, 
and  the  arms  cannot  be  brought  down  between  the  thorax  and  the 


Fig.  402. — Shoulder  and  jaw  traction.     (Mauriceau-Smellie-Veit  Method.) 


symphysis  pubis,  the  thorax  should  be  rotated  so  as  to  bring  one 
shoulder  backward,  and  the  corresponding  arm  should  be  brought 
down  first. 

If  insuperable  difficulty  is  experienced  in  bringing  down  the  arm, 
and  the  child  is  certainly  alive,  it  will  be  justifiable  to  deliberately 
fracture  the  humerus  by  pressure,  since  this  usually  overcomes  the 
difficulty,  and  it  is  better  to  deliver  a  living  child  with  a  broken 
arm  than  to  allow  it  to  succumb. 

If  the  child  is  certainly  dead,  and  the  arms  cannot  be  brought 
down  by  the  fingers,  the  small  blunt  hook,  recommended  for 
securing  the  knee  in  version,  or  the  crochet,  may  be  used  to  secure 


Extraction  of  Foetus  in  Pelvic  Presentations.    819 

them.     In  this  case  it  is  of  little  consequence  if  the  humerus  is 
fractured. 

Delivery  of  the  Head. — The  third  stage  in  the  extraction  of  the 
foetus  consists  of  the  delivery  of  the  head.  The  delivery  of  the 
head  through  a  contracted  pelvis  has  already  been  described  (see 
p.  750).  The  extraction  of  the  head  when  detained  only  by  the 
soft  parts  of  the  vaginal  outlet  has  to  be  carried  out  in  the  same 
way  as  in  a  normal  case  of  pelvic  presentation,  and  has  been 
described  at  pp.  361 — 364. 

If  the  birth  of  the  head  is  delayed  by  the  imperfectly  dilated 
soft  parts,  it  should  be  pulled  down,  if  possible,  to  the  vulva 
and  the  cervix  stripped  back  over  the  head  or  even,  if  necessary, 
incised.  This  should  only,  however,  be  done  if  the  child  is 
certainly  alive. 

Injuries  to  the  Foetus  from  Extraction  in  Pelvic  Presenta- 
tion.— Effusions  of  blood  in  the  abdomen  from  damage  to  the  liver 
or  other  viscera  are  sometimes  found,  as  are  also  effusions  of  blood 
in  the  brain  or  its  membranes.  Effusions  of  blood  may  also  take 
place  in  the  breech  or  genitals.  The  genitals  of  a  male  may  be 
injured  by  fillet,  blinit  hook,  or  forceps.  From  traction  of  the 
neck  may  result  hgematoma  in  the  sternomastoid  or  other  muscles 
of  the  neck.  This  generally  disappears  without  eventual  ill  result, 
but  sometimes  cicatricial  contraction  leads  to  wry-neck. 

Injuries  to  the  cranial  bones,  due  to  the  pressure  of  a  contracted 
pelvis,  will  be  described  hereafter  (see  Chapter  XLII.).  The 
cervical  vertebrae  may  be  separated,  and  the  spinal  cord  or  medulla 
destroyed,  from  the  effect  of  traction  upon  the  neck.  Sometimes 
even  the  body  may  be  completely  pulled  away  and  separated  from 
the  head,  but  the  spinal  column  gives  way  long  before  the  soft 
parts.  Paralysis  of  the  arm  (Duchenne's  paralysis)  may  occur 
as  the  result  of  pressure  or  tearing  of  the  upper  roots  of  the 
brachial  plexus.  By  jaw  traction  may  be  produced  fracture  of  the 
lower  maxilla,  dislocation  of  the  maxillary  joint  with  rupture  of 
ligaments,  and  also  injury  to  the  floor  of  the  mouth. 

In  attempts  to  release  the  arms  the  humerus  may  be  broken 
near  the  middle,  one  of  its  epiphyses  may  be  separated,  or  the 
clavicle  may  be  broken.  The  most  likely  lesion  to  be  produced  by 
traction  on  the  leg  is  separation  of  the  lower  epiphysis  of  the  femur ; 
but  this  is  not  common.  The  so-called  congenital  dislocation  of 
both  hips  has  been  ascribed  to  traction  on  the  legs  in  pelvic 
presentations,  but  is  really  a  fault  of  development. 

52—2 


820  The  Practice  of   Midwifery. 

A  fractured  humerus  may  be  set  with  softly  padded  splints,  the 
outer  splint  extending  the  whole  length  of  the  arm.  The  arm 
should  be  secured  to  the  side. 

If  the  femur  is  fractured,  the  child  should  be  placed  on  its  back 
with  the  legs  kept  extended  at  right  angles  to  the  body  by  a  light 
weight. 


Chaptei-  XXXIIL 
THE  FORCEPS  AND  VECTIS. 

Use  of  the  Vectis. 

The  vectis  is  one  of  the  simplest  forms  of  instrument  which  can 
be  used  for  the  extraction  of  the  head,  but  its  use  has  been,  in 
general,  abandoned  in  favour  of  that  of  forceps,  which  is  found  to 
be  both  a  safer  and  more  effective  instrument.  The  vectis  consists 
of  a  handle  and  single  blade  (Fig.  403),  having 
a  cranial  but  no  pelvic  curve.     It  somewhat  i 

resembles  a  single  blade  of  a  pair  of  straight 
forceps,  except  that  the  cranial  curve  is  much 
sharper,  especially  near  the  extremity  of  the 
instrument,  in  order  to  enable  it  to  take  a 
better  hold  of  the  head. 

This  vectis  is  generally  said  to  act  both  as  a 
lever  and  a  tractor.  Its  essential  action, 
however,  is  that  of  a  tractor  applied  to  one 
portion  only  of  the  head. 

The  Vectis  in  Occipito-posterior  Posi- 
tions.— The  vectis  is  now  practically  regarded 
by  most  authorities  as  an  obsolete  instrument. 
There  is  one  condition,  however,  in  which 
precisely  that  power  is  wanted  which  the 
vectis  is  able  to  exercise,  namely,  the  power 
of  drawing  one  pole  only  of  the  head  in  any 
required  direction.  This  is  when  labour  is  ^la.  ios.^The  vectis 
arrested  or  protracted  in  occipito-posterior 
positions  of  the  vertex,  and  the  occiput  fails  to  rotate  forwards. 
The  rotation  may  then  be  effected  either  by  a  force  actually  direct- 
ing the  occiput  forwards,  or  by  one  which  causes  flexion,  since  it  is 
through  defect  in  flexion  that  the  inclined  plane  of  soft  parts  fails 
to  turn  the  occiput  forward  as  usual  (see  pp.  260,  261).  .Both  these 
indications  are  fulfilled  by  the  use  of  the  vectis.  If  the  vectis  is 
applied  over  the  occiput  and  traction  made  towards  the  vaginal 
outlet,  as  much  forwards  as  possible,  first,  flexion  is  promoted  by 


822  The   Practice  of   Midwifery. 

the  descent  of  the  occiput,  and,  secondly,  the  occiput  is  directly 
drawn  forwards,  since  the  vaginal  outlet  is  directed  forwards  in 
reference  to  the  direction  of  the  j)elvic  axis  at  the  point  where  the 
centre  of  the  head  is  lying  (see  Fig.  22,  p.  21).  I  therefore  consider 
that  the  vectis  has  fallen  into  unmerited  disuse,  so  far  as  regards 
this  particular  case.  Even  when  called  in  to  perform  craniotomy, 
after  vigorous  efforts  to  extract  with  forceps  had  failed,  I  have 
found  that  the  occiput  could  be  turned  forwards  by  the  vectis  with 
surprising  ease,  and  that  then  extraction  by  forceps  presented  no 
difficulty  whatever.  It  is  generally  recommended  that  forceps 
should  be  applied  in  such  a  case,  and  the  head  drawn  down  in  its 
existing  position.  The  result  almost  always  is  that  the  occiput 
remains  posterior,  although,  if  the  descent  of  the  head  had  been 
effected  by  the  natural  powers,  the  occiput  would  probably  have 
rotated  forwards  at  a  late  stage.  Hence,  although  the  extraction 
may  be  successful,  yet  it  requires  more  force  than  if  the  head  had 
been  in  the  usual  position,  and  there  is  a  much  greater  probability 
of  laceration  of  the  perineum.  When  used  in  this  way  to  draw 
down  the  occiput,  the  vectis  does  in  fact  itself  form  a  lever  as  well  as 
a  tractor,  although  the  leverage  should  only  be  just  what  is  necessary 
to  secure  the  tractile  force.  For,  the  blade  being  single,  the 
inclined  plane  formed  b}'  its  distal  portion  pushes  the  head  toward 
the  centre  of  the  i^elvis,  at  the  same  time  that  the  vectis  itself  is 
pushed  against  the  pelvic  wall.  To  avoid  this  pressure  on  the 
pelvic  wall,  a  jDressure  different  from  any  produced  in  forceps 
delivery,  while  downward  traction  is  made  by  the  right  hand  on 
the  handle  of  the  vectis,  the  left  hand  should  be  placed  on  the 
shank,  as  high  up  as  it  can  reach,  and  press  it  towards  the  centre 
of  the  pelvis,  or  at  any  rate  resist  the  pressure  away  from  the 
centre  of  the  pelvis  which  the  traction  calls  into  play.  The  fulcrum 
of  the  lever  here  lies  between  the  power  and  the  resistance,  and  is 
formed,  as  far  as  possible,  by  the  left  hand,  and  not  by  the  pelvis  or 
soft  parts.  It  is  obvious  that  the  pressure  towards  the  centre  of  the 
pelvis  exerted  upon  the  occiput  is  beneficial,  since  it  aids  in  pro- 
ducing flexion,  whenever  the  occiput  is  in  any  degree  lower  than  the 
forehead  (see  Fig.  157,  p.  249). 

The  vectis  is  introduced  in  the  same  way  as  one  blade  of  the 
forceps.  The  patient  is  placed  on  the  left  side,  the  left  hand  or 
half-hand  is  introduced  into  the  vagina,  and  the  tips  of  the  fingers 
placed  upon  the  occiput,  just  within  the  rim  of  the  cervix,  if  the 
cervix  is  not  completely  retracted.  The  blade  is  passed  up  with 
its  convex  side  under  cover  of  the  flexor  surface  of  the  fingers,  and 
is  thus  guided  over  the  head.     The  blade  will  generally  have  to 


The   Forceps  and  Vectis.  823 

be  directed  nearly  in  the  direction  of  the  sacro-iliac  synchondrosis, 
or  somewhat  in  advance  of  that  point.  It  will  be  somewhat  more 
difficult  to  pass  than  a  blade  of  the  forceps,  on  account  of  its 
greater  cranial  curvature.  As  soon  as  the  occiput  has  been  brought 
to  look  somewhat  forward  instead  of  backward,  the  vectis  may  be 
removed,  and  delivery  completed  by  forceps.  If,  however,  there 
is  no  occasion  for  hurry,  it  is  well  to  allow  a  short  time  for  the 
new  moulding  of  the  head  in  its  changed  position  to  take  place. 
Delivery  also  may  sometimes  be  completed  by  the  natural  powers, 
when  once  the  position  of  the  head  has  been  rectified.  There  is 
one  condition  in  which  the  use  of  the  vectis,  as  above  described, 
is  not  available.  This  is  when  the  head  is  already  distending  the 
perineum,  and  so  close  to  the  outlet  of  soft  parts,  that  there  is  no 
longer  room  for  the  combined  movement  of  rotation  with  flexion  to 
be  effected  by  drawing  the  occiput  downward  and  forward,  especially 
when,  as  will  usually  be  the  case  at  this  stage,  the  occiput  has 
rotated  backward  into  the  hollow  of  the  sacrum. 

The  Vectis  in  Brow  Presentation. — A  much  more  rare  con- 
tingency, in  which  the  vectis  may  sometimes  be  of  use,  is  that  of 
brow  presentation.  By  applying  the  vectis  over  the  occiput,  an 
attempt  may  be  made  to  convert  the  presentation  into  a  vertex.  If 
this  fails,  the  vectis  may  be  applied  over  the  chin,  and  another 
attempt  made  to  convert  the  presentation  into  a  face. 

The  Foeceps. 

History. — The  midwifery  forceps  were  invented  by  Peter 
Chamberlen,  born  in  1601,  who,  with  his  three  sons,  long  kept 
the  invention  a  secret  for  their  own  benefit.  The  existence  of  a 
secret  method  for  saving  the  lives  of  infants  in  difficult  labour  was 
first  mentioned  in  a  pamphlet  published  in  1647.  The  invention 
gradually  became  known,  but  it  was  not  until  1735  that  Chapman, 
in  a  treatise  on  midwifery,  published  a  description  and  plate  of  the 
instrument. 

The  forceps  of  Chamberlen  did  not  essentially  differ  in  mechanism 
from  the  instrument  now  known  as  the  short  straight  forceps  (Fig. 
404,  p.  824).  Each  blade  is  straight,  viewed  in  profile,  but  has  a 
cranial  curve  to  grasp  the  head,  the  curve  starting  immediately 
from  the  lock.  The  blades  are  fenestrated,  to  lighten  the  instru- 
ment and  allow  the  head  to  bulge  through  the  fenestras ;  the 
handles  are  of  metal,  and  looped  somewhat  like  the  handles  of 
scissors.     The  lock  of  Chamberlen's  forceps  was  formed  by  a  fixed 


824 


The  Practice  of   Midwifery. 


pivot  upon  one  blade,  which  fitted  into  a  depression  or  mortise  on 
the  other  blade.  This  lock  had  to  be  secured  by  tape  tied  round  it, 
to  prevent  the  risk  of  the  blades  separating.  It  is,  in  fact,  the 
embryo  of  the  lock  still  used  in  French,  German,  and  some 
American  forceps  (see  Fig.  405),  in  which  the  pivot  is  sur- 
mounted by  an  adjustable  screw,  which  prevents  lateral  separa- 
tion at  the  lock,  and  allows  the  tightness  of  the  lock  to  be  adjusted 


Fig.  404. — Short  straight  forceps. 


Fig.  405. — Short  curved  forceps,  with 
French  lock. 


by  turning  the  screw.  This  adjustable  screw  was  first  added  by 
Levret,  who  published  a  treatise  on  midwifery  in  1766. 

The  lock  known  as  the  English  lock  (Fig.  404),  which  allows  the 
blades  to  be  joined  much  more  easily  than  any  other,  and  is 
sufficiently  firm  for  all  purposes,  was  invented  by  Smellie,  who 
also  covered  the  handles  with  wood,  for  greater  convenience  in 
grasping. 

The  Pelvic  Curve. — The  short  forceps  are  only  capable  of  grasping 
the  head  when  near  the  perineum,  or  after  its  descent  into  the 
cavity  of  the  pelvis.  In  order  to  grasp  the  head  when  arrested  at 
or  above  the  brim,  a  longer  instrument  is  necessary.     Length  may 


The  Forceps  and  Vectis. 


825 


be  attained  by  making  the  shanks  parallel  for  a  certain  distance 

beyond  the  lock  before  they  diverge  into  the  cranial  curve.     The 

instrument    thus   formed    constitutes    the    long    straight   forceps 

(Fig.  406).     If,  however,  long  straight  forceps  are  applied  to  the 

head  at  or  above  the  brim,  the  blades  can  neither  grasp  the  head  in 

the  axis  of  the  brim,  nor  can  traction  be  made  in  the  direction  of 

that  axis.     For  the  axis  of  the  brim  (o  p,  Fig.  22,  p.  21)  passes 

behind  the  tip  of  the  coccyx  when  that  bone  is  in  its  undisplaced 

position,  whereas  the  resistance  of  the  perineum,  even  when  pressed 

backward    to    the    utmost,  must    push    the 

shanks  of  the  forceps  at  the  vaginal  outlet 

much    further     forward     than     this     point. 

Practically  the  inclination  of  the  axis  of  the 

forceps  to   the  axis  of   the   brim   cannot  be 

less   than   about  20°.      In   flattened  pelves, 

especially    when    the    pelvic    inclination    is 

increased,  the  axis  of  the  brim  is  sometimes 

directed   further   back   than   usual,  and  the 

deviation  of  straight  forceps  from  the  desired 

direction  is  then  still  greater.      The  result  is 

that,  when  traction  is  made,  the  tips  of  the 

blades,  being  posterior  to  the  axis  in  which 

the  head  has  to  move,  are  apt  to  slip  off  the 

head  posteriorly.    Also  the  perineum  is  liable 

to  be  injured  from  the  pressure  made  upon 

it  in  retracting  it  to  the  utmost  extent.      The 

difficulty   thus   caused   by   the    perineum  is 

overcome  by  giving  the  forceps  an  additional 

curve,  the  pelvic  curve  (see  Fig.  408,  p.  828  ; 

Fig.  409,  p.  828 ;  Fig.  410,  p.  830).     In  this  way  are  constituted 

curved  forceps,  long  or  short,  as  the  case  may  be. 

The  invention  of  the  pelvic  curve  has  generally  been  ascribed  to 
Levret,  or  to  Smellie,  who  adopted  it  almost  simultaneously.  It 
appears,  however,  to  have  been  previously  used,  although  not 
published,  by  Benjamin  Pugh,  of  Chelmsford.  Levret's  forceps, 
introduced  about  1747,  were  long  and  powerful  curved  forceps 
with  iron  handles,  and  the  French,  or  pivot  and  mortise,  lock. 
Benjamin  Pugh,  in  a  treatise  published  in  1754,  gives  a  figure  of 
his  long  curved  forceps,  closely  resembling  the  long  curved  forceps 
now  in  use,  and  states  that  he  had  invented  them  upwards  of 
fourteen  years  before,  and  was  accustomed  to  apply  them  to  the 
head  even  when  detained  aljove  the  brim  of  the  pelvis. 

The  long  curved  forceps  are  able  to  grasp  the  head  in  the  axis 


Fia.  406.— Long  straight 
forceps. 


826 


The   Practice  of   Midwifery. 


of  the  brim  even  when  the  head  is  arrested  quite  high  up  above 
the  brim  (see  Fig.  419,  p.  844).  But  not  only  is  their  power  of 
prehension  superior  to  that  of  straight  forceps,  but  they  are  much 
easier  to  apply.  For  each  blade  passes  more  readily  along  the 
genital  canal,  in  consequence  of  its  having  a  curvature  correspond- 
ing to  that  canal,  so  that  the  tip  of  the  blade  always  passes  in 
advance.  But  when  a  straight  blade  is  passed  along  a  curved  canal, 
the  point  which  leads  the  way  is  not  the  tip  of  the  blade,  but  a 
point  more  towards  one  side,  and  the  introduction  is  then  not  so 


Fig.  407. — Diagram  illustratiDg  the  defects  of  long  curved  forceps. 
a.m.f.,  line  of  traction  ;  a.d.b.,  ideal  line  of  axis  traction  ;  a.n., 
representing  the  component  of  tractile  force  wasted  in  injurious 
pressure  against  anterior  pelvic  wall.  (Tarnier,  Description  de  deux 
nouveaux  Forceps,  Fig.  I.) 

easy.  The  advantage  gained  by  long  curved  forceps  is  strikingly 
shown  by  the  diminution  of  the  proportion  of  craniotomy  cases.  In 
the  Guy's  Hospital  Charity,  mainly  owing  to  the  introduction  of 
longer,  firmer,  and  more  effective  forceps,  the  proportion  of 
craniotomy  cases  was  reduced  from  3"6  per  1,000  in  the  interval 
1833—1854  to  1-2  per  1,000  in  the  interval  1854—1863,  and  to 
the  extremely  low  proportion  of  0*7  per  1,000  in  the  interval 
1863—1875. 

Axis-traction  Forceps. — The  ordinary  long  curved  forceps  have 
the  disadvantage  that  the  direction  of  traction  is  apt  not  to  be 
that  in  which  the  head  is  grasped,  and  in  which  it  has  to  advance. 


The  Forceps  and  Vectis.  827 

but  one  inclined  more  anteriorly.  When  the  handles  are  held  in 
one  hand  this  is  indeed  inevitable,  since  the  line  of  traction  must 
necessarily  be  a  straight  line  from  the  centre  of  the  head  to  the 
point  at  which  the  handle  is  held.  This  line  will  make  an  angle 
of  from  22°  to  25°  with  the  axis  of  the  brim,  if  the  pelvic  curve 
of  the  forceps  does  not  exceed  35°  and  the  forceps  are  held  near 
the  end  of  the  handles.  If  the  forceps  are  grasped  at  the  lock, 
the  deviation  is  somewhat  less.  The  deviation  of  the  line  of 
traction  from  the  right  direction  is  therefore  slightly  greater  than 
in  the  case  of  long  straight  forceps.  The  consequence  of  this  is 
that  rather  less  than  one-tenth  of  the  tractile  force  exercised  is 
lost  as  regards  its  effect  in  causing  advance  in  the  axis  of  the 
brim,  and  a  useless  and  injurious  pressure  is  exercised  on  the 
anterior  pelvic  wall,  equal  to  more  than  two-fifths  of  the  tractile 
force.^  The  latter  effect  seems  to  be  of  more  importance  than 
the  former,  since  the  ratio  to  the  traction  exercised  is  more  than 
four  times  as  great,  and,  moreover,  the  loss  of  one-tenth  of  the 
force  in  ordinary  cases  is  not  of  much  consequence,  since  there 
is  usually  a  sufficient  reserve  of  power  which  may  be  put  into 
action. 

It  will  be  shown,  however,  hereafter,  that  by  the  use  of  two 
hands  in  traction  the  force  exercised  may  be  made  to  act  accurately 
in  the  axis  of  the  brim,  a  fact  which  has  been  rather  overlooked  by 
the  advocates  of  axis-traction  forceps. 

To  avoid  the  disadvantage  of  an  incorrect  direction  of  traction, 
a  third  or  perineal  curve  has  been  added  to  the  forceps,  so  as  to 
make  the  shanks  and  handles  curve  backward  again  round  the 
perineum,  until  the  part  of  the  handles  to  which  traction  is 
applied  either  approximates  more  or  less  to  the  axis  of  the  blades 
or  lies  exactly  in  that  axis.  In  the  latter  case  traction  can  be 
made  precisely  in  the  axis  of  the  brim,  or  of  any  other  part  of  the 
pelvis  in  which  the  head  may  lie.  By  the  axis  of  the  blades  must 
be  understood  the  axis  of  the  extremities  of  the  blades,  since  it  is 
by  this  part  of  them  that  the  propulsive  force  is  mainly  applied  to 
the  head. 

A  slight  inverted  curve  has  been  given  to  the  shanks  of  the 
forceps  by  various  authorities,  of  whom  the  earliest  appears  to 
have  been  Dr.  liobert  Wallace  Johnston,  who  published  a  "  System 
of  Midwifery"  in  1769.  Hubert,  in  1860,  bent  the  handles  of 
his  forceps  back  almost  at  right  angles  till  their  extremities 
nearly    reached    the    axis    of    the    blades.       Aveling,     in    18G8, 

'  The  exact  proportion   in    Ihe   former   caKC,    taking  tlie  angle  at  25°,  is  1  —cos. 
:/',  or  •093()'J22,  in  the  latter,  8in.  2'/'  or  •1226183. 


828 


The   Practice  of   Midwifery. 


introduced  forceps  with  the  handles  curved  backward,  so  that 
the  whole  instrument  has  a  sigmoid  shape.  The  inverted 
curve  is  not,  however,  carried  far  enough  to  meet  the  axis 
of  the  blades.  Morales  of  Belgium,  in  1871,  gave  an  inverted 
curve  to  the  shanks  and  first  part  of  the  handles,  finishing  the 
handles  with  a  straight  portion.  In  this  case  also,  the  inverted 
curve  was  not  carried  far  enough  to  meet  the  axis  of  the 
blades.  Tarnier,  in  1877,  introduced  his  now  well-known  axis- 
traction  forceps  (Fig.  411,  p.  832).  In  these,  for  the  first  time,  the 
cross-bar  by  which  traction  is  made  lies  accurately  in  the  axis  of 


Fig.  408. — Simpson's  forceps. 


Fig.  409. — Barnes'  forceps. 


the  blades,  and  a  new  principle  is  also  introduced,  namely,  to  make 
the  traction,  not  by  the  handles  of  the  prehensile  blades,  but  by 
traction  rods  jointed  to  them  in  a  line  with  their  axis.  Tarnier's 
forceps  first  called  general  attention  to  the  principle  of  axis 
traction,  and  various  modifications  of  them  have  since  been 
introduced.^ 


Mechanical  Action  of  Forceps.— It  is  frequently  stated  that 
the  action  of  forceps  is  threefold,  namely  that  of  a  tractor,  a  lever, 

1  For  historical  sketches  of  the  various  forms  of  forceps,  see  Tarnier,  Description  de 
Deux  Nouveaux  Forceps,  Paris,  1877,  and  Aveling,  "  The  Curves  of  Midwifery  Forceps, 
their  Origin  and  Use,"  Trans.  Obst.  Soc.  London,  1878,  Vol.  XX.,  p.  130. 


The   Forceps  and  Vectis.  829 

and   a   compressor.     The   essential   action,  however,  is  that   of  a 
tractor  only.     To  carry  out   this   action   it  is  essential  that   the 
instrument  should  be  so  constructed  as  to  be  capable  of  maintaining 
a  firm  hold  of  the  head  without  slipping.     The  two  blades  of  the 
forceps  also  form  a  double  lever  like  a  pair  of  scissors,  the  fulcrum 
being  at  the  lock.     The  action  of  the  double  lever  is  to  compress 
the  head.     This  compression  of  the  head,  however,  is  not  one  of 
the  objects  aimed  at  in  the  use  of  forceps,  but  is,  on  the  contrary, 
generally   injurious,    and    should   only   be   carried   so    far    as   is 
necessary  to  secure  a  firm  hold.      For  the  blades  of  the  forceps 
being  generally  applied  at  the  sides  of  the  pelvis,  or  nearly  so,  the 
compression  of  the  head  in  the  transverse  diameter  of  the  pelvis 
tends  to  bulge  it  out  to  a  slight  extent  in  the  conjugate  diameter  of 
the  pelvis,  where  there  is  generally  least  room  for  it.     Budin  and 
Milne  Murray,^  however,  have  shown  that  the  main    elongation 
of   the   head   takes  place   in  a  vertical  diameter,  and  not  in  the 
diameter  opposite  to  that  which  is  compressed.     Besides  the  double 
leverage   causing   compression,  another  kind  of  leverage  may  be 
exercised,  not  when  simple  traction  is  used  with  forceps,  but  only 
when   an   oscillatory  or  pendulum   movement  is  made  with  the 
handles,  the  head  being  grasped  tightly  enough  to  form  an  immov- 
able mass  with  the  two  blades.     In  this  case  the  lever  is  formed, 
not  by  one  blade  of  the  forceps,  but  by  the  whole  mass  of  the  head 
with  the  two  blades.     It  will  be  seen  hereafter  that  the  oscillatory 
movement  in  traction  is  not  generally  desirable,   though  recom- 
mended by  many  authorities. 

Requirements  of  Good  Forceps. — All  patterns  of  forceps  are 
now  made  with  metal  handles,  that  they  may  be  sterilised  by 
boiling  without  risk  of  injury.  The  handles  should  be  long  enough, 
and  the  shanks  and  blades  stiff  enough,  to  maintain  the  hold  on 
the  head  even  under  strong  traction,  otherwise  the  blades  may  slip 
off  the  head,  and  diverge  at  their  widest  part,  thus  causing  pressure 
on  the  lateral  pelvic  walls.  At  the  same  time  the  tips  of  the  blades, 
as  they  slip  off,  are  liable  to  injure  the  head,  and  possibly  even  the 
maternal  soft  parts,  if  they  slip  off  anteriorly.  Good  forceps, 
therefore,  should  have  moderately  long  handles  (not  less  than 
5  inches  from  the  lock),  and  should  be  as  stiff  as  possible.  The 
quality  of  stiffness  should  be  tested  by  holding  the  handles  firmly 
together,  and  trying  how  far  the  tips  of  the  blades  can  be  separated 
by  the  finger  and  thumb.  The  advantage  to  be  gained  by  stiffness 
is  only  limited  by  the  consideration  that  the  blades  must  not  be 
1  Edinburgh  Med.  Journ.,  1888,  Vol.  XXXI V.,  Part  1,  p.  417. 


830 


The   Practice  of    Midwifery. 


made  so  thick  as  to  occupy  too  much  space  in  the  pelvis.  In  the 
shanks  a  little  extra  thickness  of  metal  may  be  employed  without 
any  drawback.  The  cranial  curve  should  be  of  medium  sharpness, 
so  that  the  elongated  head  of  average  size  may  be  grasped 
uniformly,  and  not  excessively  compressed  either  at  its  centre  or 
at  its  extremities.  A  curve  equivalent  to  the  arc  of  a  circle 
9  inches  in  diameter  is  found  to  be  generally  the  best.  If  the  curve 
is  too  sharp  the  forceps  are  more  difficult  to  introduce,  if  it  is  too 

flat  they  are  more  apt  to  slip  off  the 
head,  and,  in  both  cases,  the  head  is 
unequally  compressed.  The  tips  of  the 
blades  should  be  about  an  inch  apart 
when  the  handles  are  closed,  that  they 
may  not  be  liable  to  injure  the  head  or 
neck  by  their  pressure.  The  outside 
measurement  across  the  blades  at  their 
widest  part  should  not  be  greater  than 
3f  inches.  The  measurement  is  of 
course  increased  somewhat  beyond  this 
magnitude  when  the  forceps  are  in  use, 
if  either  the  head  is  too  large  to  allow 
the  handles  completely  to  close,  or  the 
blades  and  shanks  yield  somewhat 
under  the  traction  exerted. 

In  long  curved  forceps,  the  length 
should  be  sufficient  to  allow  the  head 
to  be  grasped  even  when  arrested  above 
the  brim,  without  its  being  necessary  to 
introduce  the  lock  within  the  soft  parts 
of  the  vulva,  and  so  run  the  risk  of 
pinching  the  mucous  membrane.  A 
length  of  about  9J  inches  from  the  lock 
If  the  length  is  increased  beyond  this, 
the  quality  of  stiffness  is  impaired  without  any  corresponding 
advantage.  The  pelvic  curve  should  not  be  greater  than  is  neces- 
sary to  allow  the  head  to  be  grasped  above  the  brim  in  the  right 
direction,  for  which  purpose  a  curve  of  from  30°  to  35°  is 
sufficient. 

If  the  curve  is  increased  beyond  the  necessary  amount,  the 
deviation  of  the  line  of  traction  from  the  correct  direction  is 
increased,  and  then  both  the  loss  of  power  and  the  useless  and 
injurious  pressure  on  the  anterior  pelvic  wall  are  increased  more 
than  in  proportion  to  the  deviation.      In   the  forceps  shown  in 


Long  curved  forceps. 


is  sufficient  for  all  cases. 


The  Forceps  and  Vectis.  831 

Fig.  405,  p.  824,  the  pelvic  curve  is  too  great,  amounting  to  about 
49° ;  and  the  same  is  true  of  many  foreign  patterns  of  forceps. 

Varieties  of  Long  Curved  Forceps. — A  great  variety  of  patterns 
of  long  curved  forceps  has  been  introduced.  Of  these  the  best 
known  in  this  country  are  Simpson's  forceps  (Fig.  408,  p.  828), 
and  Barnes'^  (Fig.  409,  p.  828).  Simpson's  forceps  have  the  most 
comfortable  handles,  the  flanges  below  the  lock  (see  Fig.  410) 
affording  an  excellent  hold  for  the  index  and  middle  fingers.  On  the 
other  hand,  they  are  scarcely  long  enough  for  all  cases  in  which  the 
head  is  high  above  the  brim.  Barnes'  forceps  have  a  more  suitable 
length,  though  in  some  recent  patterns  the  length  is  carried  to 
excess.  The  loop  above  the  lock  (see  Fig.  409)  is  also  a  great 
advantage.  It  allows  the  left  hand  to  grasp  the  forceps  high  up, 
the  index  finger  being  passed  through  the  loop  (see  Fig.  420, 
p.  848).  This  is  a  gain,  as  will  be  seen  hereafter,  with  a  view  to 
axis  traction.  The  expansion  of  the  shanks  at  this  point  also  aids 
in  guiding  the  blades  into  conjunction,  as  they  are  being  locked. 
An  excellent  form  of  forceps  is  a  combination  of  Simpson's  handles 
with  the  blades  and  shanks  of  Barnes'  forceps,  including  the  loop 
above  the  lock  for  the  insertion  of  the  index  finger  (see  Fig.  410). 
With  this  instrument,  when  two  hands  are  used,  the  index  finger 
of  the  left  hand  may  be  passed  through  the  loop,  or  two  fingers  may 
be  placed  upon  the  flanges,  according  to  circumstances.  When  one 
hand  is  used  the  index  and  middle  fingers  may  be  placed  upon  the 
flanges,  and  a  firmer  hold  thus  obtained  than  when  the  handles 
are  merely  grasped  by  their  sides. 

If  the  handles  of  the  forceps  are  very  short,  the  operator  cannot 
comj)ress  the  head  firmly  enough  by  grasping  them  to  enable  the 
blades  to  maintain  their  hold.  If  the  hold  on  the  head  is  main- 
tained at  all,  when  the  resistance  is  considerable,  it  is  because 
divergence  of  the  blades  at  their  widest  parts  is  prevented  by 
pressure  against  the  pelvic  wall.  Some  obstetric  authorities  have 
deliberately  set  themselves  to  design  forceps  with  which  the  com- 
pression of  the  head  shall  be  exercised  by  the  pelvis,  and  not  by 
the  operator.  Thus  in  Assalini's  forceps,  which  at  one  time  were 
used  by  many,  the  blades  and  handles  are  parallel  and  do  not 
cross,  so  that  practically  no  compression  can  be  exercised  by  the 
handles.  It  seems  obvious,  however,  that  the  pressure  thus 
exercised  on  the  pelvic  walls  )jy  the  wedgelike  action  of  the  diverg- 
ing forceps-blades  is  entirely  unnecessary  and  liable  to  be  injurious. 

'  The  pattern  of  these  is  similar  to  that  of  Lever's  forceps,  except  that  the  handles 
are  increased  in  length. 


832 


The   Practice  of   Midwifery. 


It  is  much  better  that  the  pelvis  should  be  subjected  only  to  so 
much  pressure  as  is  inevitable  in  the  passage  of  the  head,  and  that 
the  compression  should  be  exercised  by  the  operator,  who  can  then 
estimate  what  force  he  is  exerting,  and  limit  it  to  that  amount 
which  is  necessary  to  maintain  his  grasp  of  the  head. 

Disadvantages  and  Advantages  of  Straight  Forceps. — It  has 
already  been  explained  that,  when  the  head  is  arrested  at  or  above 
the  brim,  it  is  impossible  with  straight  forceps  of  any  length,  either 
to  grasp  the  head,  or  to  make  traction,  in  the  right  axis,  because 
the  coccyx  and  perineum  force  the  handles  forward.  In  these  con- 
ditions, therefore,  there  is  no  question  of  the  superiority  of  the 
long  curved  forceps.  The  short  straight  forceps  were  at  one  time 
recommended  for  the  low  forceps  operation  when  the  head  was  on 
the  perineum,  but  the  greater  facility  of  passing  the  blade  of  curved 


Fig.  411. — Tarnier's  axis-traction  forceps,  with  the  traction-handle  removed. 

forceps,  owing  to  its  pelvic  curve  corresponding  to  the  curve  of  the 
genital  canal  (see  pp.  824,  825),  is  quite  manifest  even  in  the  low 
forceps  operation,  and  even  when  the  head  is  on  the  perineum. 
Therefore  the  use  of  the  short  straight  forceps  presents  no  advan- 
tages over  that  of  the  long  curved. 


Axis-traction  Forceps. — It  will  be  explained  (see  pp.  847 — 848) 
how  perfectly  correct  axis  traction  may  be  made,  theoretically  at 
any  rate,  with  the  long  curved  forceps.  In  ordinary  cases  it  is  not 
difficult  to  carry  out  the  plan  described,  if  not  with  perfect  accuracy, 
yet  to  such  an  extent  that  the  disadvantage  of  the  ordinary  forceps 
as  regards  the  axis  of  traction  is  much  less  than  the  advocates  of  the 
axis-traction  forceps  have  contended.  In  difficult  cases  of  the  high 
forceps  operation,  however,  when  the  resistance  is  very  considerable, 
and  the  operator  has  to  put  out  most  of  his  strength  in  pulling,  it 
is  almost  inevitable  that  he  should  pull  nearly  straight  towards  his 
chest  with  both  arms,  instead  of  pulling  with  each  hand  in  the 
direction  of  the  corresponding  forearm  in  the  manner  described 


The  Forceps  and  Vectis. 


833 


(see  p.  848).     The  direction  of  traction  is  then  most  defective  when 
the  force  is  greatest,  and  therefore  the  pressure  on  the  pelvic  wall, 


Fig.  412. — Upper  or  right-hand  blade  of  Tarnier's  axis-traction  forceps.     Traction  rod 
detached  for  cleansing  of  hinge  (d). 

due  to  the  erroneous  direction,  most  likely  to  be  injurious.     In 
these  circumstances  axis-traction  forceps  have  a  great  advantage. 
In  Tarnier's  forceps  (Figs.  411,  412,  413)  the  instrument,  seen 


Fid.  413. — Traction  with  Tarnier's  axis-traction  forceps  when  the  head  is  at  the  brim. 
The  dotted  line  shows  the  direction  of  traction. 

from  the  side,  forms  an  S-shaped  curve,  so  far  as  regards  that  part 
of  it  which  is  used  for  traction,  the  perineal  curve  being  carried 
back  so  far  that  the  end  of  it  lies  exactly  on  the  axis  of  the  upper 
halves  of  the  blades.  Besides  the  principle  of  axis  traction,  a 
second  principle  is  embodied  in  the  instrument,  namely,  that  of 
separating  tbe  "  prehensile  branches,"  or  that  part  of  it  wbich 
M.  53 


834 


The  Practice  of   Midwifery. 


corresponds  to  ordinar}'  forceps,  from  the  "  traction  rods,"  at  the 
extremity  of  which  the  force  is  applied  by  means  of  a  strong  trans- 
verse bar,  which  allows  the  utmost  strength  of  the  operator  to  be 
put  out  by  a  firm  grasp  with  both  hands.  The  traction  rods  are 
hinged  near  the  lower  part  of  the  blades.  In  the  original  pattern 
the  prehensile  branches  had  the  same  S- shaped  curve  as  the  traction 
rods,  and  were  to  be  kept  close  to  them,  the  traction  rods  being 
made  in  one  piece.  In  the  latest  pattern  (Figs.  411,  412,  413),  the 
prehensile  branches  are  made  in  the  same  shape  as  ordinary  long 
curved  forceps,  so  that  the  bandies  lie  forward;  the  traction  rods 
are  divided  by  a  joint  in  the  middle,  at  which  the  rods  belonging 


Fig.  414. — Tarnier's  axis-traction  forceps. 

to  each  blade  are  affixed  to  a  common  handle  (Fig.  414).  This 
attachment  is  made  after  the  prehensile  branches  have  been  intro- 
duced separatel}^  and  locked.  The  prehensile  branches  take  their 
grasp  of  the  head  and  exercise  compression  upon  it,  not  b}^  being 
held  by  the  hands,  but  by  means  of  a  screw  which  approximates  the 
handles.  This  screw  should  be  tightened  only  just  when  traction  is 
made,  and  loosened  somewhat  in  the  intervals,  that  the  head  may 
not  be  subjected  to  constant  pressure.  The  whole  instrument  is 
very  stout  and  firm,  so  that  the  blades  have  the  merit  of  stiffness  in 
a  high  degree,  and  are,  in  consequence,  able  to  hold  the  head  with 
a  less  compressing  power  than  would  otherwise  be  necessary. 

It  is  claimed  that  the  prehensile  branches  form  an  ''  indicating 
needle,"  showing  the  direction  in  which  to  make  traction  at  any 


The   Forceps  and  Vectis. 


835 


moment,  and  that  the  handles  turn  forward  as  the  head  becomes 
extended  under  the  influence  of  the  pressure  of  the  genital  canal. 
The  operator,  therefore,  it  is  said,  need  not  trouble  himself  to 
discover  in  what  direction  he  ought  to  pull ;  he  has  simply  to  keep 
the  traction  rods  close  to  the  prehensile  branches  without  actually 
pushing  against  them,  and  to  pull  in  the  direction  thus  indicated. 

Tarnier's  axis-traction  forceps  have  been  much  improved,  and  the 
best  model  of  them  at  the  present  time  is  that  of  Milne  Murray  (Fig. 
422,  p.  855).  He  has  worked  out  the  construction  and  use  of  axis- 
traction  forceps  in  great  detail.  It  is  important  that  the  shanks  and 
handles  should  be  as  straight  and  as  light  as  possible,  so  that  they 


ii 

1 

LjI 

) 

1 

Fig.  415. — Axis-traction  forceps  with  screw  at  end  of  handles. 


may  in  reality  serve  as  indicating  rods.  Theoretically  the  traction 
rods  should  be  attached  in  the  centre  of  the  fenestra,  but  practically 
it  is  sufficient  if  they  are  attached  as  near  to  this  point  as  possible, 
and  for  this  reason  there  should  be  a  good  expanse  of  metal  at  the 
base  of  the  fenestree.  The  traction  rods  must  lie  parallel  to  the 
shanks  and  handles,  and  their  attachment  to  the  traction  handle 
should  be  such  that  a  straight  line  drawn  through  the  centre  of  the 
handle  so  as  to  bisect  the  line  uniting  the  two  attachments  coincides 
with  the  axis  of  the  upper  halves  of  the  blades,  when  the  rods  are 
touching  the  shanks.  In  one  pattern  of  Milne  Murray's  forceps  the 
handle  is  adjustable  so  that  the  line  of  traction  can  be  altered  to  suit 
different  pelves.  It  is  an  advantage  to  have  the  screw  uniting  the 
blades  at  the  extremity  of  the  handles  instead  of  near  the  lock,  and 

58—2 


836  The  Practice  of   Midwifery. 

to  have  the  traction  rods  readily  removable  for  cleaning  purposes 
(Fig.  415,  p.  835). 

Advantages  and  Disadvantages  of  Axis-traction  Forceps. — The  main 
advantage  of  the  instrument  is  that  it  allows  perfect  axis-traction, 
the  handle  for  pulling  being  situated  accurately  in  the  axis  of  the 
ujDper  halves  of  the  blades.  I  have  succeeded  with  it  in  extracting 
a  living  child  when  the  best  efforts  with  the  long  curved  forceps 
had  failed.  It  has  some  slight  drawbacks.  It  is  rather  more 
complicated  and  a  little  more  difficult  to  adjust  than  ordinary 
forceps.  The  hinge  at  the  blades  is  difficult  to  keep  perfectly 
clean,  whereas  with  ordinary  forceps  the  part  of  the  instrument 
introduced  into  the  vulva  has  no  point  which  is  likely  to  retain 
septic  material.  This  disadvantage  is,  however,  to  a  large  extent 
got  over  in  the  most  modern  patterns  of  these  forceps,  in  which  the 
screw  is  placed  at  the  extremity  of  the  handles  instead  of  near  the 
hinge.  The  compression  of  the  head  with  a  screw  is  also  a  dis- 
advantage. With  ordinary  forceps  the  operator,  almost  automati- 
cally, proportions  the  amount  of  pressure  to  the  traction  force 
exerted.  With  axis-traction  forceps  he  cannot  make  the  adjustment 
so  quickly,  and  he  may  omit  to  loosen  the  screw  in  the  intervals  of 
traction.  When  the  lock  is  placed  at  the  end  of  the  blades,  owing 
to  the  greater  leverage  obtained,  great  care  must  be  taken  not  to  com- 
press unduly  the  head.  In  most  cases,  however,  it  is  possible  to  use 
a  well-made  pair  of  axis-traction  forceps  with  the  slightest  possible 
tightening,  and  indeed  often  without  any  tightening,  of  the  screw  at 
all,  and  with  a  little  practice  the  loosening  of  the  screw  between  the 
pains  becomes  almost  an  automatic  action  on  the  part  of  the  operator. 

The  advantages  of  the  best  type  of  axis-traction  forceps  so  far 
outweigh  their  slight  disadvantages  that  they  should  be  chosen  for 
use  in  all  cases.  The  importance  of  being  able  to  make  correct 
axis  traction  with  one  hand  alone  in  any  position  of  the  patient  is  very 
great  indeed,  and  the  fact  that  the  use  of  axis-traction  forceps  reduces 
to  a  minimum  the  amount  of  force  required  to  deliver  a  j)atient 
reduces  the  risk  of  the  use  of  force^Ds  for  both  mother  and  child. 

Application  of   Forceps. 

The  indications  for  the  use  of  forceps  in  various  circumstances 
have  been  already  discussed.  Certain  conditions  are,  however, 
necessary  in  all  cases.  These  are  that  the  membranes  should  be 
ruptured,  that  the  os  uteri  should  either  be  fully  or  two-thirds 
dilated,  the  presentation  should  be  a  suitable  one,  there  should  not 
be  too  great  disi^roportion  between  the  head  and  the  pelvis,  and 
whenever  possible  the  head  should  be  allowed  to  become  engaged 


The   Forceps  and  Vectis.  837 

in  the  pelvic  brim  before  the  forceps  are  applied.  A  catheter  should 
first  be  passed,  to  make  sure  that  the  bladder  is  emptied,  and  the 
rectum  should  also  be  empty.  The  blades  should  be  warmed  to  a 
comfortable  temperature  in  hot  water,  and  great  care  should  be 
taken  to  make  sure  that  they  are  perfectly  clean  and  free  from  any 
septic  material.  To  this  end  the  instrument  should  not  only  be 
cleaned  with  scrupulous  care  after  use,  but  immediately  before  use 
it  should  be  disinfected  by  boiling  and  immersed  in  a  warm  solution 
of  lysol  1  in  100,  or  carbolic  acid  1  in  40.  The  hands  of  the  operator 
and  the  vulva  of  the  patient  must  be  cleansed  with  all  antiseptic 
precautions,  and  if  there  is  any  likelihood  of  the  vagina  having 
been  infected,  a  vaginal  douche  of  some  weak  antiseptic  lotion,  such 
as  lysol  1  per  cent,  or  cyllin  one  drachm  to  the  pint,  should  be  given. 

In  the  high  forceps  operation  rubber  gloves  should  be  worn,  as 
indeed  they  should  be  always  if  the  operator  has  had  to  deal  with 
any  septic  cases  recently. 

Position  of  the  Patient. — On  the  Continent,  and  in  America,  it  is 
usual  to  place  the  patient  in  the  lithotomy  position  at  the  edge  of 
the  bed ;  in  this  country  she  is  kept  in  the  usual  left  lateral  posi- 
tion, the  hips  being  merely  brought  near  to  the  edge  of  the  bed,  the 
knees  drawn  up  toward  the  abdomen,  and  the  head  and  shoulders 
directed  toward  the  opposite  side  of  the  bed,  so  that  the  trunk  lies 
transversely.  The  latter  position  involves  much  less  disturbance 
of  the  patient,  and  has  a  great  advantage  in  point  of  delicacy.  It 
also  allows  the  application  of  the  forceps  and  the  use  of  traction 
quite  as  well,  and  indeed  better.  I  or,  with  the  lithotomy  position, 
the  hips  must  quite  overhang  the  edge  of  the  bed,  otherwise  there 
is  not  room  sufficiently  to  depress  the  handles  in  the  high  forceps 
operation,  and  such  a  position  may  be  difficult  to  maintain.  The 
lithotomy  position  is  more  convenient  only  at  the  last  stage  of 
extraction,  when  the  handles  of  the  forceps  have  to  be  carried 
forward  over  the  abdomen.  Even  this  movement  may  be  accom- 
plished equally  well  with  the  lateral  position  if  the  knee  is  raised 
by  the  nurse  or  other  assistant  (see  Fig.  421,  ]3.  851).  The  mode 
of  making  axis  traction  with  ordinary  forceps,  to  be  hereafter 
described  (see  p.  847),  is  also  much  more  difficult,  if  not  impos- 
sible, to  carry  out,  when  the  patient  is  in  the  dorsal  position.  The 
lateral  position  is,  therefore,  to  be  preferred.  The  application  is 
easier  if  the  hips  are  brought  quite  to  the  edge  of  the  bed,  because 
then  there  is  plenty  of  room  to  dej^ress  the  handle  while  passing 
the  upper  blade.  This  is  not,  however,  essential,  as  will  be  seen 
hereafter,  and,  if  the  patient  is  nervous,  it  is  possiljle  to  apply  the 
forceps  without  changing  her  position. 


838 


The  Practice  of   Midwifery. 


Walchefs  Position. — It  has  already  been  mentioned,  in  the 
description  o£  the  sacro-ihac  joints  (p.  10),  that  extension  of  the 
pelvis  on  the  trunk  increases  somewhat  the  conjugate  diameter 
of  the  pelvis  and  diminishes  the  antero-posterior  diameter  of  the 
outlet,  while  flexion  has  the  opposite  effect.  The  most  effective 
mode  of  producing  such  extension  is  Walcher's  position,  in  which  the 
j)atient  is  placed  on  her  back  transversely  across  a  rather  high  bed, 
so  that  the  thighs  and  legs  hang  down  over  the  side  and  the  toes 


Fig.  416. — Diagram  showing  the  increase  in  the  conjugate  diameters  in 
Walcher's  position. 

just  touch  the  floor.  The  position  has  therefore  some  advantage  in 
forceps  extraction  through  a  contracted  conjugate,  when  the  head 
is  arrested  above  the  brim.  It  may  also  be  used  to  facilitate  the 
entry  of  the  head  even  without  the  application  of  forceps,  especially 
if  combined  with  external  pressure,  or  again  in  the  extraction  of  an 
after-coming  head  arrested  above  the  brim.  Walcher  estimated  the 
amount  of  gain  in  the  conjugate  as  8  to  13  mm. ;  Klein  at  5  to 
6  mm.  ;  Fothergill  at  9'3  mm.  on  the  average,  the  maximum  12  mm. 
AiKESthesia. — If  the  labour  is  being  conducted  without  anpes- 
thesia,  there  is  an  advantage  in  avoiding  an  ansesthetic  for  the 
application  of  forceps.  For  any  anaesthetic  diminislies  the  force 
of  the  pains  which  would  otherwise  act  in  conjunction  with  the 
tractile  force.      Moreover,  for  the  application  of  the  forceps  the 


The   Forceps  and  Vectis.  839 

anaesthesia  must  be  either  short  of  the  stage  which  completely 
abolishes  self-control,  or  must  be  pushed  nearly  to  the  full  surgical 
degree.  An  attempt  to  apply  forceps  in  the  stage  of  rigidity  and 
spasm  might  cause  injury.  If  the  anaesthetic  is  to  be  given  to  the 
full  surgical  degree,  there  should  of  course,  as  in  any  other  surgical 
operation,  be  a  skilled  administrator,  who  devotes  himself  to  this 
duty  alone.  Generally,  the  application  of  the  blades  does  not 
cause  much  pain  in  skilled  hands.  If,  therefore,  chloroform  is  being 
given  during  the  labour,  it  may  be  continued  during  the  applica- 
tion of  the  blades  to  the  extent  of  deadening  pain  without  quite 
abolishing  self-control,  and  may  be  given  to  somewhat  greater 
degree  when  traction  is  made.  If  Junker's  inhaler  is  being  used, 
the  patient  may  be  allowed  to  work  the  pump  herself,  since  she 
will  leave  off  working  it  before  becoming  deeply  narcotised.  If, 
however,  the  patient  is  very  nervous  and  difficult  to  control, 
especially  if  she  is  a  primipara  in  whom  there  is  danger  of  the 
perineum  being  ruptured,  there  is  a  great  advantage  in  having  an 
assistant  to  administer  the  anaesthetic,  and  in  having  it  given  to  a 
pretty  full  extent  at  the  final  stage  of  extraction,  since  otherwise 
a  sudden  movement  at  the  height  of  a  pain  may  render  it  impossible 
for  the  operator  to  prevent  a  rupture. 

Introduction  of  Blades. — ^With  curved  forceps  the  operator  must 
select  the  upper  or  lower  blade.  With  the  lock  made  as  it  usually 
is  made,  it  is  better,  both  with  straight  and  curved  forceps,  to 
introduce  the  loiver  or  left-hand  blade  first.  With  curved  forceps, 
if  an  inexperienced  operator  feels  at  first  any  doubt  which  blade  is 
the  lower  and  which  is  the  upper,  he  should  lock  the  blades 
together,  and  hold  them  in  a  position  similar  to  that  which  they 
are  to  occupy  when  applied  to  the  head,  noticing  that  the  concavity 
of  the  pelvic  curve  of  the  forceps  must  look  forwards. 

In  the  case  of  the  long  curved  forceps,  it  is  generally  taught  that 
the  blades  should  be  applied  at  the  sides  of  the  pelvis,  without 
regard  to  the  position  of  the  head. 

The  position  of  the  head  should,  however,  be  exactly  determined 
in  the  first  instance,  not  so  much  that  any  great  difference  in  the 
position  of  the  blades  should  be  aimed  at  in  consequence,  but 
rather  that  the  operator  may  be  made  aware  of  any  unusual 
position,  such  as  a  diagonal  or  nearly  transverse  position  of  the 
long  diameter  near  the  outlet,  or  an  occipito-posterior  jjosition, 
which  involves  an  increased  risk  of  rupture  of  the  perineum.  The 
ear  cannot  generally  be  felt  when  the  head  is  strongly  fiexed  and 
much  elongated  without  putting  the  patient  to  considerable  pain. 
Feeling  the  ear,  moreover,  is  quite  unnecessary  for  the  diagnosis  of 


840  The   Practice  of   Midwifery. 

the  exact  position.  This  may  be  made  out  with  certainty  from  the 
sutures  and  fontanelles,  or  from  the  sutures  alone,  if  the  fontanelle 
within  reach  is  lost  in  the  caput  succedaneum  (see  p.  279). 

In  the  directions  which  follow,  it  will  be  assumed  that  long- 
curved  forceps  are  used.  The  mode  of  introduction  is,  however, 
identical,  except  that,  with  axis-traction  forceps,  the  traction  rod  of 
the  upper  blade  should  be  placed  in  front  of  it  while  this  blade  is 
being  introduced. 

When  the  head  is  close  to  the  outlet  and  the  usual  rotation  has 
taken  place,  the  blades,  if  applied  exactly  at  the  sides  of  the  pelvis, 
will  grasp  the  head  nearly  at  its  sides,  or  in  an  only  slightly 
diagonal  position.  The  sides  of  the  pelvis  may  in  this  case  be 
followed  exactly  in  adjusting  the  blades.  If,  however,  the  head  is 
higher  in  the  pelvis,  and  its  long  diameter  diagonal,  or  if  it  has 
descended  quite  to  the  outlet,  and  the  long  diameter  remains 
diagonal  from  failure  of  rotation,  there  is  a  slight  advantage  in 
attending  somewhat  to  the  position  of  the  head  in  adjusting  the 
forceps.  Suppose,  for  instance,  that  the  head  lies  in  the  first  or 
left  occipifco-anterior  position.  Each  blade  may  be  passed  up  at 
the  side  of  the  pelvis,  in  the  position  in  which  it  is  found  to  glide 
up  most  readily.  But,  in  adjusting  the  blades  for  locking,  the 
upper  blade  may  be  brought  slightly  anterior  to  the  middle  line, 
and  the  lower  blade  slightly  posterior  (see  Fig.  419,  p.  844).  This 
will  cause  the  handles  (of  curved  forceps)  to  incline  somewhat 
downwards,  or  to  the  patient's  left  side.  Then,  as  the  head  is 
drawn  down  in  the  grasp  of  the  forceps,  and  the  usual  internal 
rotation  takes  place,  the  handles  will  first  rotate  to  the  front,  and 
then  probably  somewhat  over  toward  the  right  side.  For  the 
blades  will  have  grasped  the  head  somewhat  diagonally,  though 
not  quite  so  much  so  as  if  they  had  been  adjusted  at  first  pre- 
cisely at  the  sides  of  the  pelvis.  Similarly  if  the  head  lies  in  the 
second  or  right  occipito-anterior  position,  the  upper  blade  may  be 
brought  slightly  posterior  to  the  middle  line  in  adjusting  the 
forceps,  and  the  lower  blade  slightly  anterior.  If,  however,  any 
inexperienced  operator  feels  any  uncertainty  in  the  diagnosis  of  the 
position  of  the  head,  or  if  it  is  obscured  by  the  caput  succedaneum, 
he  may,  without  any  disadvantage  of  consequence,  regard  only 
the  sides  of  the  pelvis  in  adjusting  the  blades. 

In  the  high  forceps  operation,  when  the  head  is  at  or  above  the 
brim,  it  is  generally  taught  that  the  blades  are  to  be  applied  at 
the  sides  of  the  pelvis,  but  some  American  authorities  have  advised 
that  they  should  be  applied  at  the  sides  of  the  head.  Such  a 
recommendation  is  not  easy  to  carry  out.     For  in  the  flattened 


The   Forceps  and  Vectis. 


841 


pelvis  the  long  diameter  of  the  head  is  generally  almost  transverse, 
and  the  sacral  promontory  forms  a  great  obstacle  to  passing  the 
blade  of  the  forceps  over  the  side  of  the  head  which  lies  posteriorly. 
Moreover,  if  the  blades  could  be  applied  anteriorly  and  jDosteriorly, 
or  nearly  so,  the  advantage  of  the  pelvic  curve  of  the  forceps  would 
be  lost,  and  this  curve  would  become  an  absolute  inconvenience, 
being  directed  toward  the  lateral  pelvic  wall. 

The  best  plan  is  to  follow  the  same  rule  as  when  the  head  is 
lower  down  in  the  cavity,  pro- 
viclecl  that  the  long  diameter  of 
the  head  lies  obliquely,  namely, 
so  far  as  possible  to  adjust  the 
blade  corresponding  to  the 
anterior  side  of  the  head  some- 
what anterior  to  the  middle 
line,  and  the  other  somewhat 
posterior.  The  head  will  then 
not  be  quite  so  much  bulged 
out  in  the  diameter  engaged 
in  the  conjugate  diameter  of 
the  pelvis,  as  if  the  blades 
were  exactly  lateral,  and,  as  the 
head  descends  in  the  pelvis, 
the  pelvic  curve  of  the  forceps 
will  be  more  nearly  in  accord- 
ance with  that  of  the  genital 
canal,  after  the  internal  rota- 
tion of  the  head  has  taken  place. 

When,  however,  the  pelvis  is 
so  decidedly  flattened  that  the 
long  diameter  of  the  head  lies 
almost  exactly  transversely,  it 
is  better  to  adjust  one  blade 
over  the  forehead  and  the 
other  over  the  occiput,  that  is 
to  say,  to  place  the  blades  at  the  sides  of  the  pelvis.  The 
pressure  of  the  forceps  will  then  not  be  so  likely  to  displace  the 
long  diameter  of  the  head  out  of  the  most  favourable  position 
as  it  would  be  if  the  blades  caught  the  head  obliquely.  The 
head  will  probably  be  drawn  through  the  contracted  brim  in 
its  original  transverse  position.  After  the  head  has  passed  the 
brim,  and  internal  rotation  commences,  the  forceps  may  be  taken 
off  and  reajjplied,  or  they  may  be  loosened  sufficiently  to  allow 


Fift.  417. — Introduction  of  first  or  lower 
blade  of  axis-traction  forceps. 


842 


The   Practice  of   Midwifery. 


the  head  to  rotate  within  the  hlades  under  the  influence   of   the 
pelvic  pressure. 

Introduction  of  Lower  Blade. — The  operator  takes  up  his  position 
opposite  the  patient's  hips.  The  left  hand  or  half-hand  is  intro- 
duced into  the  vagina,  the  back  of  the  hand  directed  towards  the 
patient's  left  side.     If  the  margin  of  the  cervix  can  still  be  felt,  the 


Fig.  418. — Introduction  of  second  or  upper  blade  of  axis-traction  forceps. 


tips  of  the  fingers  are  placed  upon  the  head  just  within  the  cervix, 
so  as  to  make  sure  that  the  blade  of  the  forceps  passes  within  the 
cervix  and  not  outside  it.  If  the  cervix  has  retracted  quite  out  of 
reach,  the  passage  of  the  blade  in  the  right  direction  is  easily 
secured,  simply  by  keeping  the  tip  of  the  blade  in  close  contact 
with  the  head.  The  lower  blade  of  the  forceps,  sterilised  and 
warmed,  is  taken  in  the  right  hand,  and  the  end  of  the  handle  held 
very  lightly  between  the  tips  of  the  thumb  and  two  or  three  fingers. 
The  blade  is  guided  up  along  the  flexor  surface  of  the  hand  till  the 


The   Forceps   and  Vectis.  843 

point  of  the  blade  rests  on  the  head,  just  under  the  tips  of  the 
fingers  (see  Fig.  417,  p.  841).  The  handle  is  at  first  somewhat 
raised  and  directed  rather  forward,  so  as  to  allow  the  tip  of 
the  blade  to  lead  the  way  along  the  curve  of  the  genital  canal. 
As  the  blade  passes  up,  the  handle  is  carried  somewhat  backward. 
As  soon  as  the  tip  of  the  blade  rests  on  the  head,  the  curvature  of 
the  blade  must  be  made  to  correspond  with  that  of  the  head,  to 
secure  easy  progress ;  for  if  the  tip  of  the  blade  impinges  upon  the 
head  at  an  angle,  it  will  push  the  skin  of  the  head  up  in  a  fold,  and 
will  be  thereby  arrested.  For  this  purpose  it  is  generally  necessary 
to  raise  the  handle  somewhat  further.  In  pushing  on  the  blade 
into  position  over  the  head,  the  essential  point  is  to  hold  the  handle 
very  lightly,  and  overcome  any  resistance  by  change  of  direction, 
and  not  by  the  use  of  force.  As  the  blade  passes  on,  the  handle  is 
lowered  and  carried  backward,  until  the  shank  rests  against  the 
perineum.  The  flat  inner  surface  of  the  handle  should  look  nearly 
downwards  (see  Fig.  419,  p.  844).  The  easy  passage  of  the  blade 
in  this  manner  is  a  proof  that  it  is  going  in  the  right  direction. 

The  lower  blade  having  been  passed,  the  handle  should  be  given 
to  the  nurse  or  other  assistant,  who  is  to  hold  it  firmly  enough  to 
prevent  its  rotating,  keeping  it  backward  against  the  perineum 
(Fig.  418,  p.  842).  If  no  assistant  is  available,  the  handle  may  be 
allowed  to  rest  on  the  back  of  the  left  wrist,  while  the  left  hand  is 
passed  into  the  vagina  to  guide  the  upper  blade  into  position.  It  is 
always  preferable,  however,  to  have  an  assistant  to  hold  the  handle 
if  possible. 

Introduction  of  Upper  Blade. — If  the  patient's  hips  are  com- 
pletely overhanging  the  edge  of  the  bed,  the  upper  blade  may  be 
placed  in  exactly  the  same  way  as  the  lower,  the  handle  being 
depressed  instead  of  raised.  Frequently,  however,  the  edge  of  the 
bed  interferes  somewhat  with  the  handle  being  fully  depressed. 
Introduction  is  then  facilitated  by  the  plan  of  carrying  the  handle 
at  first  far  forward  close  beneath  the  patient's  left  thigh,  instead  of 
depressing  it  so  much.  The  effect  of  this  is  that  the  blade  passes 
at  first  not  up  the  side  of  the  pelvis,  but  nearly  opposite  the  right 
sacro-iliac  articulation,  a  direction  in  which  there  is  generally  more 
free  space  than  in  any  other  (Fig.  418).  When  it  has  passed  up  to 
the  required  level,  it  is  brought  round  into  position  over  the  head 
at  the  side  of  the  pelvis,  or  somewhat  anterior  to  the  middle  line  if 
the  head  is  lying  in  the  first  position,  by  carrying  the  handle  back- 
wards and  slightly  depressing  and  rotating  it.  Thus,  as  this  blade 
passes  up,  the  inner  fiat  surface  of  the  handle  looks  at  first  nearly 
backwards,  but   eventually  upwards,    or   upwards   and   somewhat 


844 


The  Practice  of   Midwifery. 


forwards  (see  Fig.  419).  To  guide  the  blade  within  the  cervix,  the 
left  hand  is  passed  into  the  vagina  in  the  same  way  as  for  the  lower 
blade,  the  back  of  the  hand  being  directed  to  the  patient's  right 
side,  and  somewhat  backwards  (Fig.  418,  p.  842). 

The  mode  of  introduction  of  the  two  blades  of  the  forceps  may  be 
summarised  as  follows  : — The  lower  blade  should  be  introduced  into 

the  vagina  with  the  handle  lying 
parallel  to  the  mother's  thigh,  and, 
to  j)ass  it  into  position  over  the 
child's  head,  the  handle  must  be 
carried  upwards  and  backwards  and 
then  downwards  and  backwards, 
describing  a  semicircle  with  its 
convexity  ujDwards.  In  the  intro- 
duction of  the  upper  blade  the 
handle  should  again  be  placed 
parallel  to  the  mother's  thigh 
while  the  blade  is  being  introduced 
into  the  vagina,  and  then  it  should 
be  carried  downwards  and  back- 
wards and  upwards  and  backwards, 
again  describing  a  semicircle,  when 
the  blade  will  slip  into  position 
over  the  child's  head. 

Locking  tlic  Blades, — The  blades 
having  been  passed  in  this  way, 
the  lock  will  be  found  in  the 
right  position  for  adjustment.  For 
locking,  the  blades  must  be  passed 
to  the  same  level,  and  the  flat 
surfaces  of  the  handles,  and 
therefore  also  the  blades,  must  be 
exactly  opposite  each  other.  If 
one  handle  is  found  to  project  more 
outside  the  vulva  than  the  other, 
it  must  be  passed  in  a  little 
further,  or  the  other  slightly  withdrawn,  until  the  two  are  exactly 
equal.  It  happens,  not  uncommonly,  that  both  blades  tend  to  turn 
somewhat  backwards  into  the  spaces  opposite  the  sacro-iliac  articula- 
tions, where  there  is  more  room  for  them  than  at  any  other  part  of  the 
pelvis.  This  tendency  is  increased  if  there  is  a  long  rigid  perineum, 
which  pushes  the  handles  forward,  and  thereby  tilts  the  upper  part 
of  the  blades  backward.      If  the  forceps  cannot  be  locked,  from  the 


Fig.  419. — Diagram  to  illustrate  intro- 
duction of  second  or  upper  blade 
of  long  curved  forceps,  the  head 
being  in  the  first  position.  A  B, 
lower  blade  already  introduced, 
adjusted  somewhat  posterior  to  the 
left  side  of  the  pelvis,  c  d,  position 
of  upper  blade  as  it  approaches  the 
head,  c'  d',  its  final  position  just 
before  locking,  adjusted  somewhat 
anterior  to  right  side  of  pelvis, 
c  c',  D  d',  paths  of  end  of  handle 
and  tip  of  blade.  The  flat  internal 
surface  of  the  handle  looks  at  first 
backwards  and  slightly  upwards, 
finally  upwards  and  slightly  for- 
wards, in  consequence  of  the  rota- 
tion of  the  blade. 


The   Forceps  and  Vectis.  845 

handles  not  being  opposite  to  each  other,  this  rotation  of  the  blades 
will  be  found  most  frequently  to  be  the  cause  of  difficulty ;  for  the 
effect  of  it  is  that  the  flat  interior  surfaces  of  both  handles  are 
inclined  forward,  instead  of  being  exactly  opposite  to  each  other. 
To  overcome  the  difficulty,  the  lower  handle  should  be  taken  in  the 
right  hand  and  the  upper  handle  in  the  left,  and  both  handles 
pressed  backward  toward  the  perineum.  This  will  bring  the  upper 
part  of  the  blades  forward  over  the  head  to  the  sides  of  the  pelvis. 
At  the  same  time,  both  handles  are  to  be  rotated  in  opposite  direc- 
tions until  the  flat  surfaces  exactly  face  each  other,  and  the  forceps 
will  then  at  once  lock.  In  making  this  adjustment,  as  has  already 
been  mentioned,  it  is  a  good  plan,  when  the  long  diameter  of  the 
head  is  diagonal,  to  bring  the  blade  corresponding  to  the  anterior 
side  of  the  head  in  front  of  the  middle  line,  and  the  other  behind  it. 
The  upper  blade  will  then  be  somewhat  anterior,  when  the  head  is 
in  the  first  position,  the  lower  blade,  when  the  head  is  in  the  second 
position.  If  the  handles  can  be  easily  brought  together,  or  nearly 
brought  together,  after  locking,  it  is  a  sign  that  the  blades  are 
rightly  adjusted  within  the  uterus.  As  the  blades  are  locked,  if  the 
lock  is  near  to  the  vulva,  care  must  be  taken  that  no  mucous  mem- 
brane or  hair  is  caught  in  it. 

When  the  force]3s  are  locked,  the  fingers  should  be  introduced 
to  make  sure  that  the  blades  are  properly  applied  to  the  head  and 
within  the  os  uteri.  Not  more  than  about  one-third  of  the  fenestras 
of  the  blades  should  be  felt  lying  free  below  the  head.  If  the  head 
is  very  large  and  much  elongated,  nearly  the  whole  of  the  fenestrge 
may  be  in  contact  with  the  head.  If,  when  traction  is  made,  a 
greater  and  greater  proportion  of  the  fenestra  can  be  felt  below  the 
head,  this  will  indicate  that  the  blades  are  slipping  off. 

There  is  generally  a  groove  round  the  handles  of  the  forceps,  to 
enable  the  handles  to  be  tied  together.  Tying  the  handles  is,  how- 
ever, quite  unnecessary  and  bad  practice.  If  they  are  held  lightly 
in  the  intervals  of  traction,  the  forceps  will  not  become  unlocked ; 
and  it  is  important  that,  in  these  intervals,  the  head  should  be  entirely 
relieved  from  the  pressure  of  the  blades.  If,  therefore,  the  operator 
should  desire  to  tie  the  handles  together,  in  order  to  be  able  entirely 
to  let  them  go,  they  should  be  tied  only  quite  loosely,  sufficiently  to 
prevent  their  becoming  unlocked,  but  not  to  cause  any  pressure 
upon  the  head. 

If  the  handles  are  found  completely  to  close  together  with 
moderate  pressure,  it  is  a  sign  that  the  head  is  small,  and  is  not 
grasped  in  one  of  its  long  diameters.  If,  on  the  other  hand,  they 
remain  considerably  apart,  it    may  be    inferred  that   the  head  is 


846  The   Practice  of   Midwifery. 

large,  or  is  seized  in  one  of  its  long  diameters.  If  the  separation 
of  the  handles  is  very  great,  a  hydrocephalic  head  may  be  suspected. 

Mode  of  making  Traction. — If  the  pains  are  still  normal  in 
character,  traction  should  be  made  only  during  the  pains,  so  that 
the  artificial  help  may  be  combined  with  the  natural  force.  The 
only  exception  to  this  is  the  case  in  which,  at  the  final  stage  of 
extraction,  there  is  danger  of  the  perineum  being  ruptured, 
especially  when  the  patient  is  a  primipara,  and  difiicult  to  control. 
It  is  then  often  better  to  extract  the  head  in  the  interval  of  pains, 
so  that  the  exact  degree  of  force  may  be  regulated,  and  vasij  not 
be  liable  to  be  disturbed  by  a  sudden  expulsive  effort.  If  the 
pains  have  become  inefi^ective,  and  occur  only  at  long  intervals,  or 
if  the  uterus  has  passed  into  a  state  of  continuous  action,  traction 
should  be  made  at  intervals  corresponding  to  those  of  the  natural 
pains ;  for  discontinuous  pressure  is  less  likely  to  be  injurious, 
both  to  mother  and  child,  than  continuous  pressure,  the  circula- 
tion being  restored  in  the  intervals  of  rest.  The  handles  should 
be  compressed  during  traction,  and  the  compression  should  be 
proportional  to  the  tractile  force  exerted,  so  that  a  firm  hold  may 
be  maintained  on  the  head.  In  the  intervals  of  traction,  the 
compression  should  be  taken  oft'. 

Resistance  of  Cervix. — In  those  cases  in  which  forceps  are  applied 
with  a  cervix  not  yet  fully  dilated,  before  any  effort  is  made  at 
extraction,  the  operator  should  ascertain  whether  the  resistance  to 
the  advance  of  the  head  is  due,  in  part  or  in  whole,  to  the  cervix. 
For  this  purpose  moderate  traction  may  be  made  on  the  handles 
with  the  right  hand,  while  the  left  hand  is  passed  into  the  vagina 
to  feel  whether  the  effect  of  this  traction  is  to  put  the  cervix  on 
the  stretch,  and  to  what  extent.  In  general,  if  the  cervix  is  the 
cause  of  difiiculty,  it  will  be  the  external  os  which  forms  the 
obstacle.  In  some  cases,  however,  especially  when  labour  has  been 
brought  on  rapidly  in  consequence  of  some  condition  dangerous  to 
the  mother,  such  as  eclampsia,  the  internal  os  will  be  found  to 
be  not  fully  dilated,  and  to  be  forming  a  rigid  barrier.  If  the 
obstruction  is  due  to  incomplete  dilatation  of  the  cervix,  much 
longer  time  must  be  allowed  for  delivery  with  the  forceps,  often  as 
much  as  an  hour  or  even  two  hours.  Otherwise  the  cervix  is  likely 
to  be  lacerated,  and  then  there  is  an  increased  risk  of  septic 
absorption  and  pelvic  cellulitis,  as  well  as  of  subsequent  chronic 
uterine  disease  set  up  by  the  ununited  laceration  and  consequent 
eversion  of  the  cervix.  In  order  to  bring  about  gradual  dilatation 
of  the  cervix  the  traction  must  be  gentler  and  more  continuous 
than  when  the  obstruction  is  due  to  the  pelvis,  and  the  finger 


The   Forceps  and  Vectis.  847 

should  be  frequently,  if  not  constantly,  testing  the  degree  of  strain 
which  is  placed  upon  the  tissues.  In  some  cases  of  contraction  of 
the  brim  the  cervix  is  not  fully  dilated  because  the  head  is  arrested 
above  the  brim,  and  not  able  to  descend  upon  it  and  complete  the 
dilatation  after  the  escape  of  the  liquor  amnii.  It  may  then  be 
necessary  to  make  powerful  traction  at  first,  to  cause  the  head  to 
enter  the  pelvis  and  descend  upon  the  cervix,  and  then,  when  this 
stage  has  been  reached,  to  be  very  gentle,  and  allow  ample  time 
for  the  cervix  gradually  to  yield. 

When  no  part  of  the  resistance  is  due  to  the  cervix,  extraction 
may  be  made  more  rapidly,  especially  if  the  perineum  also  forms 
no  obstacle.  But  in  all  cases  of  forceps  delivery  there  should  be 
no  hurry,  and  time  should  be  allowed  for  moulding  of  the  head. 
The  time  required  for  extraction  in  such  cases  may  vary  from  a 
few  minutes  to  half  an  hour  or  more,  according  to  the  resistance 
encountered. 

Direction  of  Traction. — The  object  is  in  general  to  make  traction 
in  the  direction  of  that  part  of  the  pelvic  axis  (see  Fig.  22,  p.  21) 
in  which  the  centre  of  the  head  lies.  This  is  the  direction  in 
which,  if  the  forceps  are  correctly  applied,  the  head  is  grasped  by 
the  upj)er  portions  of  the  blades,  that  is  to  say,  by  those  portions 
which  alone  communicate  to  it  the  onward  impulse  (see  Fig.  420, 
p.  848).  In  a  normally  shaped  pelvis  it  must  be  remembered 
that  the  direction  of  the  axis  is  practically  straight  as  far  as  the 
central  plane  of  the  pelvis,  and  that  it  is  inclined  at  an  angle  of 
55°  or  60°,  nearly  two-thirds  of  a  right  angle,  to  the  axis  of  the 
woman's  body.  Traction  has  therefore  to  be  made  as  nearly  as 
possible  in  the  axis  of  the  brim,  downward  and  backward,  with 
any  position  of  the  head,  from  one  quite  above  the  brim  to  one  in 
which  the  advanced  part  of  the  head  is  beginning  to  press  upon 
the  inclined  perineal  body  or  pelvic  floor,  the  centre  of  the  head 
having  reached  the  central  plane  of  the  pelvis.  From  this  point 
onward  the  direction  of  traction  must  be  carried  rather  rapidly 
forward,  until  at  the  outlet,  if  the  perineum  was  previously  intact, 
the  direction  has  been  changed  through  an  angle  of  as  much  as 
135°,  and  is  now  almost  horizontally  forward,  in  reference  to  the 
axis  of  the  mother,  the  handles  of  the  forceps  being  carried  up 
over  the  abdomen.     (See  Fig.  22,  p.  21,  and  Fig.  421,  p.  851.) 

Direction  of  Traction  in  Flattened  Pelves. — In  flattened  jDelves 
there  is  often  posterior  obliquity  of  the  uterus  in  reference  to  the 
axis  of  the  brim,  especially  if  the  pelvic  inclination  is  increased. 
Regard  must  then  be  paid  to  the  "curve  of  the  false  promontor3^" 
If  the  head  is  lying  loose,  high  above  the  l)rira,  when  the  forceps 


848 


The   Practice  of   Midwifery. 


are  applied  over  it,  the  centre  of  the  head  may  lie  behind  the  axis 
of  the  brim,  the  head  being  held  back  by  the  anterior  uterine 
wall,  in  consequence  of  the  posterior  obliquity  of  the  uterus. 
Traction  must  then  be  made  at  first  a  little  more  forward  than 
the  axis  of  the  brim,  in  order  to  get  the  head  to  enter  the  brim. 
A  little  later,  when  the  centre  of  the  head  is  passing  the  brim  and 
rounding  the  promontory  of  the  sacrum,  the  backward  inclination 
of  the  traction  should  be  somewhat  increased,  so  as  to  bring  the 
head  into  the  hollow  of  the  sacrum.  Then,  as  in  the  ordinary 
case,  the  traction  should  be  continued  in  nearly  the  same  direction 


Fig.  420. — Mode  of  making  axis  traction  with  ordinary  long  curved  forceps. 
A,  centre  of  head,  as  grasped  by  the  forceps,  p,  Q,  forces  exerted  by  the 
two  hands.  H  D,  E  F,  directions  of  forces,  P,  Q.  A  X,  A  Y,  perpendiculars 
from  A  upon  E  F,  H  D.     A  K,  axis  of  brim.     E,  resultant  of  P  Q. 


till  the  advanced  part  of  the  head  begins  to  press  upon  the  pelvic 
floor,  and  afterwards  shifted  rather  rapidly  forwards. 

When,  however,  the  uterus  is  active,  and  the  head  is  pressed 
down  upon  the  brim,  the  centre  of  the  head  will  generally  lie,  if 
anything,  anterior  to  the  axis  of  the  brim  from  the  first :  for  the 
uterine  force  presses  the  head  downward  and  forward  in  reference 
to  the  axis  of  the  brim,  and  the  last  lumbar  vertebra  pushes  it 
forward  somewhat  over  the  edge  of  the  brim,  if  it  is  too  large 
readily  to  enter.  Any  Naegele-obliquity  which  may  exist  (see 
pp.  262 — 267)  will  also  bring  the  centre  of  the  head  more  forward. 
In  this  case  the  traction  must  from  the  first  be  directed  well 
backward,  somewhat  more  posteriorly  than  the  axis  of  the  brim. 


The   Forceps  and  Vectis.  849 

Axis  Traction. — The  only  way  in  which,  with  long  curved  forceps, 
it  is  possible  to  exercise  traction  accurately  in  the  direction  of  the 
pelvic  axis  at  the  brim  or  at  any  other  point,  and,  at  the  same 
time,  in  the  direction  of  the  upper  halves  of  the  blades,  is  to  grasp 
the  handles  with  two  hands.  The  mode  in  which  traction  can,  in 
this  way,  be  made  in  the  axis  of  the  brim,  assuming  that  an  equal 
tractile  force  is  put  out  by  the  two  hands,  is  illustrated  in  Fig.  420. 
The  forceps  are  held  by  the  right  hand  at  the  extremity  of  the 
handles,  and  by  the  left  hand  near  the  lock,  the  forefinger  being 
passed  through  the  loop  above  it.^ 

The  following  is  the  rule  for  exercising  axis  traction  with 
ordinary  forceps.  Grasp  the  forceps  in  the  way  shown  in  the 
figure.  Let  the  right  forearm  be  inclined  slightly  forwards  (at  an 
angle  of  about  25°)  in  reference  to  the  handles  of  the  forceps, 
and  the  left  forearm  be  about  at  right  angles  to  the  right.  Then 
pull  with  each  hand,  not  directly  forwards  to  the  chest,  but  in  the 
line  of  the  corresponding  forearm,  and  let  both  hands  pull  with 
equal  strength. 

The  forearms  will  naturally  be  in  the  position  above  described, 
namely,  about  at  right  angles  to  each  other,  if  the  elbows  are  kept 
near  the  sides.  The  inclination  of  the  two  arms  to  the  forceps  is 
also  that  at  which  the  hands  can  most  easily  and  naturally  grasp 
them.  In  order,  therefore,  to  make  axis  traction  with  ordinary 
forceps,  the  operator  has  not  to  make  any  careful  estimate  of 
angles.  He  has  only  to  take  hold  of  the  forceps  in  the  right  way, 
and  hold  them  in  the  most  natural  manner,  keeping  his  elbows 
near  his  sides,  and  merely  to  remember  that  the  traction  of  each 
hand  ought  not  to  be  directly  towards  the  chest,  but  in  the  line  of 
the  corresponding  forearm. 

It  is  obvious  that  for  axis  traction  exercised  in  this  way  Barnes' 
forceps  have  an  advantage  over  Simpson's,  since  the  loop  above  the 


1  The  mechanical  conditions  necessary  to  secure  the  required  result  are  two.  First 
the  product  of  the  force  P  exercised  by  the  left  hand  and  the  perpendicular  A  Y  from 
Ihe  centre  of  the  head  upon  its  direction  must  be  equal  to  the  product  of  Q,  the  force 
exercised  by  the  right  hand  and  the  corresponding  perpendicular  A  X  upon  its 
direction.  The  operatfjr  need  not,  howevei',  trouble  himself  about  this  condition,  for, 
in  order  to  fulfil  it,  he  has  only  so  to  pull  that  the  handles  are  not  carried  either 
forwaifl  or  Vjackward. 

The  second  condition  is  not  quite  so  easy  to  fulfil  exactlj'.  It  is  that  the  lines  of 
traction  with  the  two  hands  must  be  equally  inclined  to  the  axis  of  the  brim.  The  two 
lines  of  traction  (x  v,  Y  D,  see  Fig.  420)  will  then  meet  upon  the  axis  of  the  brim  A  B, 
and  the  direction  of  Jt,  the  resultant  of  the  two  forces,  will  coincide  with  the  axis  of 
the  brim.  It  will  be  seen  by  the  figure  that  the  inclination  of  the  two  forces  to  each 
other  ought  to  be  about  a  light  angle,  with  foi'ceps  of  the  ordinary  shape  and  length, 
assuming  that  the  two  hands  pull  with  equal  force.  The  line  of  traction  of  the  rigiit 
hand  should  be  inclined  about  2'/'  in  advance  of  the  direction  of  the  handles,  the  line 
of  traction  of  the  l<;f't  liand  about  <)"/'  behind  it. 

M.  54 


850  The   Practice  of   Midwifery. 

lock  in  the  former  gives  a  convenient  hold  for  the  left  hand  at  a  greater 
distance  from  the  end  of  the  handles  than  the  flanges  of  Simpson's 
forceps.  With  the  forceps  shown  in  the  figure  (see  also  Fig.  420, 
p.  848)  the  finger  should  be  jDassed  through  the  loop,  not  rested  on 
the  flanges,  if  axis  traction  is  desired. 

The  case  given  above  is  the  niost  simple  one.  If  the  hands  pull 
with  unequal  strength,  the  desired  result  may  be  attained  in  many 
different  ways.  Thus,  if  the  left  hand  pulls  more  strongly  than 
the  right,  or  if  the  left  hand  grasj)s  the  forcej)s  higher  up  the  shanks, 
the  proper  direction  of  traction  for  the  left  hand  is  not  directed  so 
much  backward,  and  the  two  directions  of  traction  need  not  diverge 
by  so  great  an  angle  as  a  right  angle. 

By  this  method  it  is  possible,  with  ordinary  forceps,  to  secure 
axis  traction  with  considerable  approximation,  if  not  with  absolute 
exactitude ;  and  a  slight  deviation  from  the  true  direction  is  not 
of  much  consequence.  Suppose,  for  instance,  that  the  deviation 
is  10° ;  tben  the  amount  of  force  lost  as  regards  the  advance  of  the 
head  is  only  about  one-fiftieth  of  the  whole,  and  the  unnecessary 
pressure  on  the  pelvic  wall  about  one  thirty-sixth  of  the  force 
employed. 

The  mode  in  which  the  use  of  two  hands  enables  the  traction  to 
be  made  more  backward  than  it  otherwise  could  be  may  be  explained 
by  saying  that  the  two  blades  of  the  forceps,  united  in  one  mass 
with  the  head,  form  a  lever,  the  fulcrum  being  the  point  grasped  by 
the  left  hand  and  fixed  by  the  traction  of  that  hand.  The  traction 
of  the  right  hand,  ajiplied  at  the  end  of  the  handles  and  inclined 
forwards,  therefore  tends  to  tilt  the  centre  of  the  head,  at  the 
opposite  end  of  the  lever,  backwards. 

In  all  cases  in  which  the  head  lies  at  or  above  the  brim  or  at 
some  height  in  the  cavity  of  the  pelvis  it  is  desirable  when  using 
the  long  curved  forceps  to  adopt  the  plan  of  traction  with  two  hands 
which  has  been  here  described ;  for  even  if  the  operator  does  not 
trouble  himself  about  judging  exactly  the  correct  position  of  the 
arms,  the  resultant  force  is  likely  to  be  more  nearly  in  the  right 
direction  than  if  traction  were  made  simply  from  the  centre  of  the 
head  to  the  lock  or  end  of  the  handles.  If  resistance  is  slight, 
there  is  no  harm  in  drawing  with  the  right  hand  only,  two  fingers 
being  placed  over  the  flanges,  or  one  finger  through  the  loop  above 
the  lock,  and  this  method  allows  the  left  hand  to  be  passed  into  the 
vagina  in  order  to  feel  the  tension  of  the  cervix,  or  judge  whether 
the  blades  are  keeping  in  position ;  for  the  pressure  on  the  anterior 
pelvic  wall  so  produced  is  not  then  likely  to  be  great  enough  to  do 
any  mischief. 


The   Forceps  and   Vectis. 


851 


Traction  to  he  steady,  not  oscillatory. — As  a  rule  traction  should 
be  steady  in  the  direction  judged  to  be  the  right  one,  without  any 
swaying  of  the  handles  of  the  forceps,  although  such  a  "  pendulum 
movement  "  has  been  recommended  by  many  authorities.  The 
exceptional  cases  in  which  an  exertion  of  leverage  by  oscillatory 
movement  of  the  handles  is  admissible  will  be  considered  hereafter. 
If,  however,  the  head  is  found  not  to  advance,  it  is  desirable  some- 
what to  vary  the  direction  of  traction  in  a  tentative  way,  to  see  if 
some  direction  may  not  be  found  in  which  traction  is  more  effective ; 
for  the  operator  may  not  have  been  quite  accurate  in  his  judgment 
of  the  direction  of  the  pelvic  axis  at  the  point  where  the  centre  of 


Fig.  421. — Mode  of  delivering  head  through  vulval  outlet. 

the  head  is  lying,  or  there  may  be  some  peculiarity  of  the  pelvis 
which  he  has  not  been  able  to  discover. 

Amount  of  Force  to  be  exerted. — Experience  alone  can  enable  the 
practitioner  to  judge  accurately  the  amount  of  force  which  may 
be  exerted  with  safety  to  the  mother,  and  the  time  during  which 
it  may  safely  be  prolonged.  It  is  to  be  remembered  that  the  use 
of  forceps,  as  compared  with  craniotomy  in  a  doubtful  case,  is  an 
operation  for  the  interest  of  the  child,  and  that  it  is  not  justifiable 
seriously  to  endanger  the  mother,  in  order  to  save  the  child.  In  a 
difficult  case,  the  operator  may  find  it  necessary  to  have  an  assistant 
to  press  against  the  patient's  buttocks,  in  order  to  keep  her  in 
position,  A  person  not  of  great  muscular  power  may  sometimes 
have  to  put  out  as  much  tractile  force  as  he  can  exert  in  a  steady 
manner. 

54—2 


852  The  Practice  of   Midwifery. 

The  child's  head  should  never  be  pulled  through  the  pelvic  brim 
by  brute  force,  a  method  of  delivery  entailing  great  danger  both  to 
the  mother  and  the  child.  As  much  time  as  can  with  safety  be 
given  should  be  allowed  to  elapse  to  permit  of  moulding  of  the 
head  taking  place,  and  no  premature  attempts  should  be  made  to 
pull  the  unmoulded  head  through  a  contracted  brim. 

The  amount  of  force  which  may  be  used  legitimately  with  forceps 
has  been  estimated  as  considerably  exceeding  100  lb. ;  but  there  has 
never  been  any  satisfactory  determination  of  the  limit  of  force  which 
is  really  safe  for  the  mother. 

Mode  of  'Traction  at  the  Vaginal  Outlet. — When  the  head  begins 
to  distend  the  j)erineal  body,  or  inclined  plane  of  soft  parts  forming 
the  pelvic  floor  (see  Fig.  421,  p.  851),  the  mode  of  traction  with 
long  curved  forceps  should  be  altered.  The  resistance  is  now  due 
to  the  soft  parts,  and  has  to  be  overcome  rather  by  gradual  exten- 
sion than  by  great  force,  in  order  to  avoid  laceration  as  far  as 
possible.  The  right  hand  alone  may  now  be  used  for  traction, 
while  the  left  hand  is  used  to  estimate  the  tension  placed  upon  the 
vaginal  outlet,  or  to  shield  the  perineum  by  pressure  exercised  in 
front  of  the  sacro-sciatic  ligaments,  in  the  manner  recommended  for 
cases  of  ordinary  labour  (see  p.  302),  and  shown  in  Fig.  197,  p.  303. 
The  inclination  of  the  tractile  force  forward  in  reference  to  the  axis 
of  the  genital  canal  is  not  now  a  disadvantage,  since  it  is  chiefly 
the  posterior  wall  of  the  genital  canal  which  is  in  danger  of 
laceration,  and  the  natural  expulsive  force  is  itself  inclined  back- 
ward toward  that  posterior  wall.  In  primiparge,  and  in  all  cases 
where  laceration  of  the  perineum  appears  to  be  threatened,  much 
time  should  be  allowed  at  this  stage,  and  the  vaginal  outlet  should 
be  very  gradually  stretched,  in  imitation  of  nature,  by  successive 
efforts,  with  intervals  between  them.  If  the  uterus  is  acting 
vigorously,  traction  with  the  forceps  should  not  be  made  with  the 
pains,  but  only  in  the  intervals.  During  the  pains  the  too  rapid 
advance  of  the  head  should  be  checked,  partly,  as  in  natural  labour, 
by  pressure  upon  it  with  the  left  hand,  partly  by  actually  resisting 
it  with  the  forceps,  the  handles  being  pressed  rather  back  instead 
of  carried  forward. 

Grasp  of  Right  Hand  to  be  shifted. — As  the  head  first  begins  to 
approach  the  outlet,  traction  may  be  made  by  the  right  hand 
grasping  the  handles  in  the  usual  way,  two  fingers  being  rested 
on  the  flanges,  or  one  finger  passed  through  the  loop  above  the 
lock.  The  handles  have  now  to  be  swept  rather  rapidly  forward, 
and  eventually  carried  up  somewhat  in  front  of  the  abdomen.  To 
allow  this  the  patient's  leg  should  be  held  up  by  the  nurse  or 


The    Forceps  and  Vectis.  853 

other  assistant  (Fig.  421).  At  the  stage  when  the  occiput  is 
beginning  to  emerge  at  the  vulva,  the  grasp  of  the  right  hand 
should  be  shifted,  so  that  the  palm  of  the  hand  is  transferred  from 
the  anterior  to  the  posterior  surface  of  the  handles,  and  the  hand 
is  now  used  to  push  rather  than  to  pull,  the  left  hand  being  spread 
out  in  front  of  the  sacro-sciatic  ligaments,  to  keep  the  head  forward, 
and  so  relieve  the  strain  on  the  perineum.  Not  much  force  can 
thus  be  exercised,  but  only  a  very  little  is  wanted.  The  final 
emergence  of  the  head  should  be  managed  with  extreme  slowness, 
the  tension  of  the  edge  of  the  perineum  being  estimated  by  the 
left  hand.  It  should  be  remembered  that  the  maximum  tension  is 
reached  just  at  the  moment  when  the  forehead  is  passing  the 
perineal  margin. 

liemoval  of  Blades. — As  soon  as  the  chin  is  clear  of  the  perineum 
the  blades  are  easily  removed.  In  some  cases,  when  it  is  not  the 
resistance  of  the  perineum  which  has  required  the  application  of 
forceps,  but  some  obstacle  at  a  higher  level,  and  when  there 
appears  to  be  danger  of  laceration,  the  uterus  acting  vigorously, 
it  is  desirable  to  unlock  and  remove  the  blades  before  the  head 
has  passed  the  vulva,  that  the  tension  may  not  be  increased 
even  by  the  small  amount  of  space  which  the  blades  themselves 
occupy. 

The  Leverage  Action  of  Forceps. — When  the  head  is  tightly 
grasped  by  the  forceps,  so  that  the  head  and  two  blades  form  one 
solid  mass,  and  an  oscillatory  or  pendulum  movement  is  made  with 
the  handles,  a  kind  of  leverage  may  be  exercised  which  aids  the 
advance  of  the  head. 

When,  therefore,  the  head  is  engaged  in  the  pelvic  canal,  and 
impacted  in  it  by  friction  so  that  it  cannot  readily  be  pushed  back 
in  the  interval  of  a  pain,  and  when  moderate  direct  traction  fails 
to  cause  any  advance  of  the  head,  oscillatory  movement  of  the 
handles  may  be  cautiously  tried  before  recourse  is  had  to  cranio- 
tomy. The  oscillation  should  be  limited  in  degree,  and  with  each 
oscillation  should  be  combined  firm  compression  of  the  handles, 
so  as  to  make  the  head  one  solid  mass  with  the  blades,  and  the 
maximum  of  traction  which  it  is  thought  safe  to  exert.  The 
oscillation,  to  be  of  service,  should  also  be  in  that  diameter  in 
which  the  head  is  most  tightly  gripped  by  the  pelvis.  Thus  in  a 
flattened  pelvis  it  should  be  backward  and  forward,  in  a  uniformly 
contracted  pelvis  it  may  be  in  both  directions,  or  the  two  may  be 
combined  in  a  limited  circular  movement.  Side-to-side  movement, 
in  a  flattened  pelvis,  is  entirely  useless,  and  only  likely  to  be 
injurious.     The  oscillatory  movement   should   not   be   persevered 


854  The   Practice  of   Midwifery. 

with  long,  unless  the  head  is  found  to  advance  with  it,  for,  if  the 
leverage  is  successfully  called  into  play,  there  must  be  an  advance 
at  each  oscillation. 

The  mechanism  by  which  this  movement  causes  advance  is 
analogous  to  that  by  which  a  cork  is  got  out  of  a  bottle  by  pushing 
it  from  side  to  side,  and  also  to  that  by  which  a  tight  ring  is 
removed  from  a  finger  by  pulling  first  one  side  and  then  the  other 
instead  of  pulling  the  two  sides  together.  Both  these  instances 
show  that  by  leverage  advance  can  be  effected  by  less  force  than 
would  otherwise  be  necessary.  Moreover,  the  shape  of  a  cork,  a 
long  cylinder,  is  much  more  unfavourable  for  such  leverage  than 
that  of  an  ovoid  body  like  the  foetal  head. 

The  operator  may  fail  in  his  effort  to  exert  leverage  in  two  ways. 
(1.)  The  blades  may  slip  backward  and  forward  over  the  head, 
instead  of  holding  it  as  one  solid  mass  with  themselves.  The  head 
is  then  likely  to  be  injured  by  the  friction.  (2.)  The  head  may 
simply  sway  backward  and  forward  on  its  central  axis,  instead  of 
advancing.  The  friction  is  then  most  likely  to  do  damage  to  the 
maternal  soft  parts. 

There  is  another  way  in  which  a  very  slight  oscillatory  move- 
ment may  be  of  advantage  when  the  head  is  impacted  in  the  pelvic 
canal  by  friction.  This  depends  upon  the  fact  that  statical  friction, 
or  friction  between  bodies  at  rest,  is  always  greater  than  dynamical 
friction,  or  friction  between  bodies  in  motion,  especially  when  the 
bodies  have  been  long  in  contact.  When  friction  is  a  main  element 
of  the  resistance,  a  slight  oscillatory  movement  of  the  head  may 
convert  the  statical  friction  into  the  lesser  dynamical  friction  over 
the  greater  part  of  its  surface.  For  this  purpose  the  slightest 
possible  oscillation  of  the  handles  is  sufficient,  provided  that  the 
head  is  held  tightly  enough  to  take  part  in  it. 

Reason  for  applying  the  Loicer  Blade  first. — It  has  been  recom- 
mended that  the  lower  blade  of  the  forceps  should  be  introduced 
first,  although  some  authorities  give  the  contrary  advice.  The 
reason  for  choosing  the  lower  blade,  with  forceps  made  in  the 
usual  way,  depends  upon  the  construction  of  the  lock.  On  refer- 
ring to  Fig.  419  (p.  844),  it  will  be  seen  that,  if  the  lower  blade  is 
introduced  first,  and  the  handle  held  backward,  then  the  handle  of 
the  second  blade  passes  in  anterior  to  that  of  the  first,  and  the  two 
handles  are  at  once  in  the  right  position  for  locking.  If  the  upper 
blade  had  been  introduced  first,  and  the  handle  held  backward, 
then  the  handles  would  have  been  in  the  wrong  position,  and  the 
lock  could  not  have  been  adjusted  without  reversing  the  relative 
position  of  the  shanks.       Some  authorities  teach  that  the  upper 


The   Forceps  and  Vectis. 


855 


blade  should  be  introduced  first,  and  the  handle  held  forward 
while  the  second  blade  is  being  introduced,  the  assistant  standing, 
not  behind  the  patient's  back,  but  in  front  of  her  knees.  The 
second  blade  is  then  passed  up  behind  the  handle  of  the  first,  and 
the  handles  come  into  the  right  position  for  locking.  The  objection 
to  this  is  that,  when  the  handle  is  held  forward,  the  blade  is  only 
half  applied  over  the  head — in  the  high  forceps  operation  scarcely 
so  much  as  half  applied — ^and  is  therefore  more  liable  to  become 
displaced.  It  is  also  impossible  to  dispense  with  an  assistant  for 
holding  the  first  handle.  This  may  be  managed,  as  already 
described  (see  p.  843),  when  the  lower  blade  is  introduced  first,  by 
resting  the  first  handle  on  the  back  of  the  wrist.  If,  therefore,  it 
is  desired  to  introduce  the  upper  blade  first,  it  is  better  to  have  the 
lock  of  the  forceps  made  in  the  reverse  way  to  the  ordinary  one 


Fig.  422. — Axis-traction  forceps. 


The  upper   blade  can  then  be  passed  first,  and  the  handle  held 
backward  while  the  second  blade  is  introduced. 

The  lock  of  the  forceps  can,  of  course,  be  made  equally  well 
either  way.  Assuming  that  the  forceps  have  yet  to  be  constructed, 
there  are  some  advantages  each  way  to  be  considered  in  deciding 
whether  the  lock  should  be  fitted  for  the  introduction  of  the  lower 
or  of  the  upper  blade  first.  If  the  lower  blade  is  passed  first  it  is 
not  80  likely  to  get  out  of  place  from  the  effect  of  gravity  as  the 
upper  blade  would  be,  while  the  second  blade  is  being  introduced. 
On  the  other  hand,  the  upper  blade  is  the  more  difficult  to 
introduce.  There  is,  therefore,  a  certain  advantage  in  introducing 
the  upper  blade  first,  so  that  the  difficulty  is  not  increased  by 
the  vagina  being  already  occupied,  to  some  extent,  by  the  first 
blade.  Individually,  I  prefer,  on  the  whole,  the  introduction  of  the 
upper  blade  fh-st,  and  have  therefore  had  the  lock  of  my  axis-traction 
forceps  (Fig.  428)  made  in  the  reverse  way  to  the  ordinary  lock. 


8s6 


The  Practice  of   Midwifery. 


Application  of  Axis-traction  Forceps. — For  introduction  of 
the  axis-traction  forceps,  each  traction  rod  is  held  with  the  corre- 
sponding prehensile  branch  like  a  single  blade,  the  lower  blade  being 
introduced  first.  It  is  most  convenient  in  introducing  the  upper 
blade  to  place  the  traction  rod  in  front  of  the  handle  until  the 
blade  has  been  placed  in  position  and  then  to  carry  it  back  into  its 
proper  position  in  relation  to  the  handle.  The  lock  can  then  be 
adjusted,  and  the  screw  which  approximates  the  handles  turned 
until  the  head  is  sufficiently  grasped.  The  two  traction  rods  are 
then  brought   together  and   the  common  handle  fitted  over  their 

ends. 

In  making  traction  the  operator  should  hold  the  handle  so  that 
the  traction  rods  come  as  close  as  possible  up  to  the  pre) i ensile 
branches,  without  pushing  the  handles  of  the  latter  forward. 
Fig.  407,  p.  826,  shows  how  traction  is  thus  made  accurately  in  the 
axis  of  the  brim,  or  of  any  other  plane  of  the  pelvis  in  which  the 
centre  of  the  head  is  lying.      As  the  handles  of  the  prehensile 


Fig.  423. — The  aiithfir's  axis-traction  forceps. 


branches  move  forward,  the  traction  handle  is  moved  forward  also, 
so  that  the  traction  rods  are  kept  close  up  to  the  prehensile 
branches. 

In  making  traction  with  axis-traction  forceps,  there  is  no  necessity 
to  alter  the  grasp  of  the  hands ;  the  traction  should  always  be  made 
on  the  traction  handle,  never  upon  the  handles  of  the  forceps 
themselves  even  when  the  head  is  on  the  perineum. 

In  the  original  types  of  axis-traction  forceps  the  prehensile 
branches  were  so  heavy,  and  their  weight  acted  at  so  great  a 
mechanical  advantage  by  leverage,  that  their  utility  as  an  indicator 
of  the  path  pursued  by  the  head  was  very  small.  In  the  modern 
instruments,  as  the  handles  are  much  smaller  and  lighter,  they  act 
in  this  way  much  more  certainly,  and  although,  no  doubt,  they  do 
not  indicate  with  complete  accuracy  the  direction  in  which  axis 
traction  should  be  made,  yet  the  error  is  but  slight  and  practically 
of  little  importance. 

In  order  to  gain  the  advantage  of  axis  traction  without  the  draw- 
backs to  the  ordinary  types  of  axis-traction  forceps,  which  have  been 


The   Forceps  and  Vectis.  857 

enumerated  above,  I  have  had  constructed  the  forceps  shown  in 
Fig.  423.  With  these  I  have  found  that  a  Hving  child  can  in  some 
eases  be  extracted  when  all  efforts  with  the  ordinary  long  curved 
forceps  have  failed.  The  general  shape  of  the  instrument  is  similar 
to  that  invented  by  Morales,  of  Belgium,  but  the  perineal  curve  is 
carried  back  more  completely  to  the  axis  of  the  upper  halves  of  the 
blades,  and  the  lock  is  the  English  instead  of  the  French  lock.  The 
handles  lie  in  the  axis  of  the  upper  halves  of  the  blades.  Hence 
traction  has  to  be  made  simply  in  the  line  of  the  handles,  as  with 
straight  forceps,  and  if  it  is  desired  to  rotate  the  head,  this  can  be 
done  by  simply  rotating  the  handles  on  their  own  axis.  The  oj)erator 
must  judge  for  himself  the  direction  of  the  pelvic  axis  at  the  point 
where  the  centre  of  the  head  is  lying,  as  in  the  case  of  the  ordinary 
forceps,  and  keep  the  handles  in  that  direction.  The  lock  is  made 
in  the  reverse  of  the  ordinary  way,  in  order  that  the  upper  blade 
may  be  introduced  first,  and  the  handle  held  backward  while  the 
second  blade  is  being  passed. 

It  will  be  found  that  these  forceps  can  be  applied  more  easily 
than  ordinary  axis-traction  forceps.  The  adjustment  of  the  lock  is 
easier  even  than  with  ordinary  forceps,  because  the  transverse 
portion  below  the  lock  affords  a  considerable  leverage  in  rotating 
the  shanks  by  means  of  the  handles,  so  as  to  bring  the  flat  surfaces 
of  the  handles  exactly  opposite  to  each  other,  and  the  blades 
therefore  into  the  right  position  to  lock.  With  this,  as  with  the 
long  curved  forceps,  the  operator  has  however  to  judge  the  correct 
direction  in  which  to  make  axis  traction,  and  since  it  is  more 
difficult  to  determine  this  in  a  contracted  pelvis,  with  this  type,  as 
with  the  long  curved  forceps,  the  operator  is  most  likely  to  fail  in 
the  very  cases  in  which  it  is  most  important  to  make  correct  axis 
traction. 

Forceps  in  Occiinto-posterior  Positions  of  the  Vertex. — So  long  as 
the  occiput  looks  in  any  degree  backwards,  the  application  of  forceps 
should  be  deferred,  if  possible,  or  the  occiput  should  first  be  rotated 
forwards  manually  or  by  the  vectis,  in  the  manner  previously 
described  (see  p.  821)  ;  for  if  the  head  descends  under  the  influence 
of  the  natural  forces  the  occiput  will  probably  rotate  forwards,  but 
if  it  is  grasped  by  forceps,  this  rotation  will  almost  certainly  be 
prevented,  and  the  danger  of  laceration  of  the  perineum  will 
thereby  be  increased.  The  manreuvre  recommended  by  Scanzoni 
is  practised  by  some  obstetricians  in  these  cases.  The  forceps  are 
applied  accurately  to  the  sides  of  the  head.  For  example,  in  a  third 
or  right  occipito-posterior  presentation  they  are  thus  applied  in  the 
left  oblique  diameter  of  the  pelvis.     The  head  is  then  drawn  down  to 


858  The  Practice  of   Midwifery. 

the  pelvic  floor,  rotation  forwards  of  the  occiput  being  favoured  by 
rotation  of  the  handles  of  the  forceps.  In  this  way  the  head  is 
rotated  so  that  the  long  diameter  of  the  head  turns  into  the  trans- 
verse diameter  of  the  pelvis,  and  finally  the  occiput  looks  somewhat 
forwards.  The  forceps  are  then  taken  off  and  again  applied  to  the 
sides  of  the  head  in  the  opposite  oblique  diameter.  Delivery  of 
the  head  is  then  effected,  the  complete  rotation  of  tlie  occiput  to  the 
front  at  the  same  time  being  induced  by  further  rotation  of  the 
handles  of  the  forceps.  If  the  occiput  remains  backwards,  forceps 
should  only  be  applied  for  the  purpose  of  extraction  if  the  condition 
of  the  mother  calls  for  their  use,  or  if  it  is  judged  that  there  i?  no 
chance  of  rotation  taking  place,  from  the  fact  that  the  head  is  already 
low  upon  the  perineum,  and  the  occiput  rotated  backwards  into  the 
hollow  of  the  sacrum. 

The  blades  should  be  applied  in  the  same  way  as  in  occipito- 
anterior positions,  and  in  this  case  no  attempt  should  be  made  to 
rotate  the  head  artificiall}^  but  it  should  be  extracted  over  the 
perineum  with  extreme  care  and  slowness,  in  consequence  of  the 
increased  risk  of  laceration.  If  any  tendency  of  the  occiput  to 
rotate  forwards  is  noticed,  the  blades  should  be  removed,  so  as  to 
permit  rotation  of  the  head  to  take  place,  if  possible,  under  the 
influence  of  the  natural  forces,  and  then  reapplied. 

Forceps  in  Face  Presentations. — In  face  presentations,  where  the 
chin  is  directed  forward,  forceps  may  be  used  with  almost  as  much 
advantage  as  in  vertex  presentations.  The  blades  should  be 
applied  as  nearly  as  possible  to  the  sides  of  the  face.  The  handles 
(of  long  curved  forceps)  will  then  be  directed  at  first  somewhat  to 
the  side.  As  the  chin  rotates  under  the  pubic  arch,  the  handles 
will  turn  forward. 

Mento-posterior  Positions. — In  the  majority  of  cases,  the  chin  is 
directed  posteriorly  or  transversely.  There  is  then  considerable 
risk  to  the  child  in  the  use  of  forceps  ;  for  if  one  blade  is  applied 
over  the  chin,  its  tip  will  compress  the  neck  and  trachea,  and  is 
liable  to  do  such  damage  that  the  child  may  be  still-born,  or  die 
shortly  after  birth.  Hence  in  all  such  cases  the  rule  is  the  same 
as  in  occipito-posterior  positions  of  the  vertex — that  the  case 
should  be  left  to  nature  as  long  as  possible,  unless  the  condition 
of  the  mother  requires  interference.  It  is  to  be  remembered  that, 
although  labour  is  more  protracted  than  in  vertex  presentations, 
the  immense  majority  of  cases  terminate  naturally  if  left  alone. 

If  the  head  is  arrested  high  up  in  face  presentation,  version  is 
the  best  treatment  if  the  uterus  is  not  too  rigid  to  allow  it.  If 
version  is  not  admissible,  and  the  chin  posterior,  forceps  may   be 


The   Forceps   and  Vectis.  859 

applied  as  nearly  as  possible  to  the  sides  of  the  head,  the  concavity 
of  the  pelvic  curve  necessarily  looking  toward  the  forehead.  The 
head  may  be  drawn  down  in  this  position  until  it  rests  completely 
upon  the  j)erineum.  The  forceps  should  then  be  taken  off,  and 
the  chin  will  frequently  rotate  forwards  at  the  last  moment  under 
the  pressure  of  the  perineum.  Sometimes  it  rotates  only  partially 
forwards,  and  the  face  passes  the  vulva  almost  in  a  transverse 
position.  Sometimes,  with  a  small  head,  the  chin  may  be  drawn 
over  the  perineum  with  the  forceps,  the  edge  of  the  perineum 
being  hooked  backward  over  the  chin  as  soon  as  possible. 

If  the  face  is  arrested  high  up  in  a  transverse  position,  and 
version  is  not  admissible,  the  only  chance  for  the  child,  although 
a  poor  one,  is  ■  to  apply  the  forceps  in  whatever  way  they  will 
seize  the  head.  They  may  be  taken  off  as  before  when  the  head 
is  drawn  quite  down  upon  the  perineum. 

If  the  face  is  arrested  when  resting  low  upon  the  perineum, 
and  the  chin  remains  posterior,  the  attempt  may  be  made  to  effect 
rotation  artificially,  although  it  is  dangerous  to  do  this  when  the 
head  is  high  up.  The  blades  are  applied  to  the  sides  of  the  head, 
the  concavity  of  the  pelvic  curve  necessarily  looking  toward  the 
forehead.  Kotation  is  effected  by  carrying  the  handles  more  to 
the  side  and  in  a  backward  direction,  the  head  being  at  the  same 
time  firmly  grasped. 

As  soon  as  the  handles  begin  to  look  somewhat  posteriorly  and 
the  chin  somewhat  anteriorly,  the  forceps  are  taken  off,  and 
reapplied  with  the  concavity  of  the  pelvic  curve  toward  the 
chin.  Extraction  is  then  easily  completed  by  drawing  down- 
ward and  at  the  same  time  aiding  the  rotation  of  the  handles  to 
the  front. 

Forceps  applied  to  the  After -coming  Head. — The  value  of  the 
application  of  forceps  in  head-last  cases  has  been  very  variously 
estimated  by  different  authorities.  The  difference  may  depend 
upon  the  degree  of  dexterity  with  which  operators  have  tried 
other  modes  of  extraction.  When  the  resistance  is  due  to  soft 
-parts  only,  forceps  will  rarely,  if  ever,  be  required,  if  the  method 
of  extraction  previously  described  (see  pp.  361 — 364)  is  properly 
carried  out. 

When  the  resistance  is  due  to  the  pelvis,  the  very  short  space 
within  which  the  child  must  be  extracted,  if  extracted  alive,  allows 
but  little  time  for  the  application  of  the  Ijlades,  somewhat  impeded 
by  the  presence  of  the  child's  body,  and  for  extraction,  especially  if 
time  has  already  been  occupied  by  attempts  to  extract  by  traction 
on  the  trunk.     The  only  advantage  is  that  greater  force  may  be 


86o  The   Practice  of   Midwifery. 

exerted.  Accordingly,  although  some  authorities  speak  highly  of 
the  application  of  forceps  to  the  after-coming  head,  I  have  not 
found  it  so  efficacious  as  traction  on  the  body,  combined,  if  neces- 
sary, with  jaw-traction.  It  may  be  preferable,  however,  in  the  case 
of  the  pelvis  gequabiliter  justo  minor,  or  one  contracted  in  its  trans- 
verse diameter.  Even  in  the  flattened  pelvis,  it  maj^be  tried  if  the 
other  method  fails. 

For  application  of  forceps  to  the  after-coming  head,  the  body  of 
the  child  should  be  drawn  as  much  forward  as  possible,  and  held 
forward  between  the  patient's  thighs  by  an  assistant  who  grasps 
the  legs.  The  arms  should  be  previously  released,  if  extended 
above  the  head,  and  these  also  should  be  kept  forward.  The 
blades  of  the  forceps  are  then  to  be  introduced  posterior  to  the 
child's  body,  and  so  applied  to  the  head.  If  necessary,  a  moderate 
degree  of  traction  applied  by  an  assistant  to  the  body  may  be 
combined  with  the  force  exerted  by  the  forceps  upon  the  head. 
Such  traction  may  assist  in  elongating  the  head,  and  so  enabling  it 
to  pass  the  brim. 


Chapter    XXXIV* 

VERSION, 

By  version  is  meant  the  operation  for  altering  the  position  of  the 
foetus,  so  that  the  presenting  part  is  changed,  and  one  or  other 
pole  of  the  foetus  is  brought  over  the  os  uteri.  Classifying  the 
operation  according  to  the  part  of  the  foetus  which  is  made  to 
present,  the  chief  varieties  of  version  are  cephalic  version,  in  which 
the  head  is  made  to  present,  and  podalic  version,  in  which  one  or 
both  feet  are  brought  down.  Pelvic  version,  in  which  the  breech 
is  made  to  present  without  a  foot  being  brought  down,  is  rarely 
performed.  According  to  the  mode  of  its  performance,  version  is 
divided  into  three  classes — external  version,  effected  by  external 
manipulations  only ;  internal  version,  effected  by  the  hand  intro- 
duced within  the  uterus,  the  external  hand  being  used  only  to 
steady  the  uterus  ;  and  the  combined  external  and  internal  version, 
in  which  one  hand  is  used  in  the  vagina  and  the  other  moves  the 
foetus  by  pressure  through  the  abdomen. 

History. — Version  is  a  very  ancient  operation.  Before  the 
introduction  of  forceps  it  was  used  more  than  it  is  at  present, 
because,  in  cases  of  contracted  pelvis,  it  was  the  only  possible  mode 
of  saving  the  foetus.  Cephalic  version,  recommended  by  Hippo- 
crates, was  at  first  alone  in  use,  and  was  extensively  practised, 
being  employed  even  in  pelvic  presentations.  Podalic  version  was 
introduced  in  the  latter  part  of  the  sixteenth  century,  and  taught 
by  Pare,  Guillemeau,  Mauriceau,  and  others.  At  first  it  was  the 
custom  to  bring  down  both  feet ;  Portal  adopted  the  modern  plan 
of  bringing  down  only  one  foot,  but  he  did  not  teach  this  as  a 
principle,  and  the  advantage  of  bringing  down  the  half-breech 
alone  was  pointed  out  definitely  by  Puzos  in  1759.^  On  account  of 
the  greater  facility  of  podalic  version,  cephalic  version  afterwards 
fell  almost  entirely  out  of  use,  until  revived,  for  a  certain  limited 
class  of  cases,  by  recent  authorities. 

Cephalic  Version.— For  the  performance  of  ceplialic  version  it 
is   essential  either  that  the  membranes  should  be  intact,  and  the 

'  Fasbciider,  (JcHcliiclile  <ler  OcburLslilillV,  I  DOG,  [>.  H«l. 


862 


The   Practice  of   Midwifery. 


fcetus  movable  in  the  liquor  amnii,  or  at  any  rate,  that  the  liquor 
amnii  should  have  only  recently  escaped,  and  the  uterus  be  quite 
lax,  so  as  to  allow  ready  mobility  of  the  foetus.  Cephalic  version 
should  not  be  attempted  in  any  case  in  which  rapid  delivery  is 
called  for,  or  in  any  case  of  flattened  pelvis  in  which  there  is  any 
considerable  contraction  of  the  conjugate  diameter,  for  in  such 
pelves  the  head  is  likely  to  pass  better  when  it  enters  the  brim 
with  the  base  first.  It  is  considered  advisable  by  some  writers  to 
perform  cephalic  version  in  cases  of  slight  deformity  of  the  pelvis, 
since  after  the  version  has  been  carried  out  the  relation  of  the  size 


Fig.  424. — External  cephalic  version  with  the  woman  in  the  Trendelenburg 

position. 

of  the  head  to  that  of  the  pelvis  is  more  easily  determined.  Other- 
wise cephalic  version  is  preferable  to  podalic  in  all  uncomplicated 
cases  of  shoulder  or  transverse  presentation  in  which  it  can  be 
performed  without  much  difficulty,  for  the  risk  to  the  child  is  much 
less  if  it  passes  with  the  head  first  than  if  it  is  extracted  by  the 
feet.  Cephalic  version,  however,  frequently  requires  more  dexterity 
on  the  part  of  the  operator  than  the  ordinary  podalic  version. 

Cephalic  Version  by  the  External  Method.  —  Cephalic 
version  by  external  manipulation  only  is  chiefly  available  for  those 
cases  in  which  a  transverse  or  oblique  position  of  the  axis  of  the 
foetus  is  discovered  before  the  onset  of  labour.  It  may  be  employed, 
however,  even  after  labour  has  commenced,  provided  that  the 
liquor  amnii  is  intact,  and  the  uterus  is  completely  relaxed  in  the 


Version.  863 

intervals  of  pains.  For  the  operation  the  patient  is  placed  on  her 
back,  the  head  rested  on  a  low  pillow,  the  abdomen  uncovered,  or 
covered  only  by  a  thin  garment.  As  much  relaxation  as  possible  of 
the  abdominal  muscles  should  be  secured.  In  cases  where  difficulty 
is  experienced  or  where  the  head  is  already  engaged  in  the  brim  of 
the  pelvis  Pollock^  recommends  very  strongly  the  use  of  the 
Trendelenburg  position,  or  elevating  the  patient  by  the  legs  until 
the  trunk  is  almost  vertical  (Fig.  424).  It  is  essential  that  it  should 
be  possible  to  make  out  with  certainty,  by  external  palpation,  the 
parts  of  the  fretus,  especially  the  head  and  the  breech,  the  head 
being  distinguished  by  its  hardness  and  uniform  rounded  form. 
Then,  at  a  time  when  the  uterus  is  comj)letely  lax,  the  head  is 
pushed  toward  the  os  uteri  with  one  hand,  and  the  breech  toward 
the  fundus  with  the  other.  In  many  cases  the-  foetus  rotates  with 
great  facility,  especially  if  its  long  axis  was  originally  transverse. 
It  should  be  allowed  to  rotate  in  whichever  direction  it  will  most 
readily,  but  care  should  be  taken  if  possible  not  to  cause  extension 
of  the  body.  In  cases  of  difficulty  the  help  of  an  assistant  to  fix 
one  pole  of  the  child  will  be  found  an  advantage.  Not  un- 
commonly, the  displacement  occurs  again,  from  the  same  cause 
which  produced  it  in  the  first  instance.  There  is,  however, 
no  harm  in  making  the  reposition  once,  even  if  the  axis  of  the 
child  again  gets  out  of  position.  The  only  thing  necessary,  if 
labour  has  not  yet  come  on,  is  to  take  care  that  the  foetus  is  again 
restored  to  the  right  position  in  the  early  stage  of  labour  and 
before  the  rujDture  of  the  membranes. 

Supposing  that  labour  has  commenced,  and  that  the  head  has 
been  brought  over  the  os  uteri,  the  patient  should  be  kept  quiet 
in  bed,  and  not  allowed  to  walk  about,  lest  the  malposition  be 
reproduced  through  displacement  of  the  fundus  uteri.  In  general 
it  is  better  to  keep  the  patient  uniformly  on  her  back,  so  that 
there  may  be  no  inclination  of  the  fundus  to  one  side  or  the  other. 
If,  however,  there  is  a  marked  natural  inclination  of  the  fundus 
toward  one  side,  it  may  be  desirable  to  counteract  this  by  making 
the  patient  lie  on  the  opposite  side,  or  with  some  inclination 
toward  the  opposite  side.  As  soon  as  dilatation  of  the  os  has 
progressed  to  some  extent,  the  fixation  of  the  head  in  the  pelvis 
will  be  promoted  by  rupturing  the  membranes. 

In  pelvic  presentations  external  version  may  be  performed  during 
the  last  weeks  of  pregnancy,  or  even  at  the  onset  of  labour.  It  is 
best  performed  about  the  thirty-fourth  to  the  thirty-sixth  week. 

'    I'ollock,  'I'ntiis.  Obst.  Soc.  London,  ]W)C>,  Vol.  XLVllf.,  p.  819. 


864  The  Practice  of   Midwifery. 

Cephalic  Version  by  the  Combined  External  and  Internal 
Method. — In  former  days  cephalic  version  was  performed  by 
passing  the  hand  into  the  uterus,  grasping  the  head,  and  drawing 
it  toward  the  os.  As  this  was  a  more  difficult  operation  than  the 
ordinary  podalic  version,  and  one  which  involved  more  risk  of 
injury  to  the  mother,  it  rightly  fell  into  disuse.  Various  methods 
of  combining  the  action  of  the  two  hands,  one  passed  into  the 
vagina,  and  one  applied  externally  to  the  abdomen,  have  been 
described  by  Busch,  Hohl,  and  Wright  of  Cincinnati.  The  plan, 
however,  which  can  be  employed  with  least  disturbance  to  the 
mother  is  that  first  published  by  Dr.  Braxton  Hicks, -^  which  can 
be  carried  out  when  only  one  or  two  fingers  can  be  passed  through 
the  cervix.  Whenever  a  shoulder  presentation  is  discovered  before 
the  rupture  of  the  membranes,  and  there  is  no  contraction  of 
moment  of  the  conjugate  diameter  of  the  pelvis,  and  no  other 
reason  for  interference  than  the  malposition  of  the  foetus,  it  is 
worth  while  to  endeavour  to  secure  a  head  presentation  by  this 
method.  Even  when  the  liquor  amnii  has  escaped  it  may  be 
possible  to  carry  it  out,  provided  that  it  has  escaped  only  recently. 
Even  descent  of  the  arm  was  not*  considered  by  Dr.  Hicks  as  a 
contra-indication ;  but  in  such  case,  the  arm  must  first  be  returned 
across  the  chest.  Generally  when  the  arm  is  prolapsed,  the  foetus 
will  not  be  movable  enough  to  allow  cephalic  version. 

Method  of  operating. — The  bladder  and  rectum  should  be 
empty,  as  in  all  obstetric  operations.  Anaesthesia  is  not  abso- 
lutely necessary,  but  it  always  facilitates  the  operation,  and  should 
be  employed  at  any  rate  in  those  cases  in  which  the  introduction 
of  the  hand  into  the  vagina  is  difficult  or  excites  spasm,  or  in 
which  the  uterus  is  contracting  frequently,  and  there  is  a  risk  that 
the  membranes  will  be  ruptured.  Dr.  Hicks  recommended  that 
the  patient  should  be  placed  on  the  left  side,  and  the  left  hand 
introduced  into  the  vagina,  as  for  podalic  version.  As  a  general 
rule,  it  will  be  found  most  convenient  to  place  the  patient  on  the 
right  side  when  the  left  hand  is  used  internally,  and  on  the  left 
side  when  the  right  hand  is  used  internally.  The  position  of  the 
head  and  breech  must  be  first  made  out,  and  these  parts  recognised 
by  external  palpation.  Then  one  or  two  fingers  of  the  gloved  hand 
are  introduced  through  the  cervix,  placed  upon  the  apex  of  the 
shoulder,  and  the  shoulder  is  by  their  means  pushed  upward  in 
the  direction  of  the  breech  and  away  from  the  head.  As  soon  as 
the  shoulder  begins  to  recede,  the  external  band,  placed  uj)on  the 

1  "On  Combined  External  and  Internal  Version,"  Trans.  Obst.  Soc.  Loudon,  1864, 
Vol.  v.,  p.  219, 


Version.  865 

abdomen  over  the  head,  pushes  the  head  down  into  the  pelvic 
brim  over  the  os  uteri.  The  shoulder  still  rising,  the  head  can  be 
received  upon  the  tips  of  the  inside  fingers.  The  head  will  play 
like  a  ball  between  the  two  hands,  the  membranes  being  still 
intact,  and  can  be  adjusted  at  will  over  the  os.  If  the  breech  does 
not  readily  rise  to  the  fundus  after  the  head  is  fairly  in  the  os,  the 
hand  should  be  withdrawn  from  the  vagina,  and  used  to  push  up 
the  breech  from  the  exterior  in  the  direction  of  the  fundus.  It  is 
only  at  this  last  stage  that  the  method  becomes  truly  "  bipolar," 
the  forces  being  applied  to  the  opposite  ends  of  the  foetus. 

Choice  of  Position. — When  the  head  is  displaced  toward  the 
patient's  left  side,  and  the  breech  therefore  toward  the  right,  there 
is  no  doubt  that  it  is  best  to  make  her  lie  on  her  left  side,  as 
recommended  by  Dr.  Hicks,  for  then  gravity  assists  the  movement 
of  the  breech  toward  the  fundus.  When,  however,  the  head  is 
displaced  to  the  right  side  and  the  breech  to  the  left,  I  have  found 
it  better,  in  order  to  get  a  similar  assistance  from  the  action  of 
gravity  on  the  fundus  uteri  and  the  breech  towards  rectifying  the 
position  of  the  child's  axis,  to  place  the  patient  on  her  right  side. 
The  left  hand  may  then  be  passed  into  the  vagina,  and  the  right 
hand  used  externally  over  the  abdomen. 

Some  have  recommended  the  use  of  the  knee-elbow  position, 
that  the  foetus  may  gravitate  away  from  the  pelvic  brim,  and  so 
the  recession  of  the  shoulder  may  be  facilitated.  When  vaginal 
space  is  ample  and  the  patient  tolerant,  so  that  an  anaesthetic 
may  be  dispensed  with,  the  position  may  be  tried,  if  the  shoulder 
is  not  found  easily  to  recede  with  the  lateral  position.  In  other 
cases  an  approximation  may  be  made  to  the  effect  of  the  knee- 
elbow  position  by  adopting,  instead  of  the  simple  lateral  position, 
the  Trendelenburg  position  or  Sim's  semi-prone  position,  in  which 
the  lower  arm  is  extended  straight  behind  the  back,  the  chest  is 
rotated  so  as  to  rest  downward  against  the  bed,  and  the  upper  knee 
is  flexed  more  than  the  lower,  the  knee  also  being  in  contact  with 
the  bed. 

Podalic  Version.— Podalic  version  is  to  be  performed  in  all 
cases  of  shoulder  or  transverse  presentation  in  which  cephalic 
version  is  contra-indicated,  or  cannot  readily  be  carried  out.  These 
comprise  much  the  largest  proportion  of  the  whole.  Podalic 
version  is  also  indicated  when  the  head  is  presenting  in  many 
cases  of  placenta  praevia,  in  some  of  accidental  haemorrhage,  in 
certain  cases  of  flattened  pelvis,  in  some  of  prolapse  of  the  funis, 
in  some  brow  presentations  and  mento-posterior  presentations  of 


866 


The  Practice  of   Midwifery. 


the  face,  and  also  in  cases  in  which  rapid  delivery  is  called  for  on 
account  of  some  perilous  condition  of  the  mother,  such  as  eclampsia. 
The  grounds  for  deciding  on  the  oj)eration  in  any  given  case  are 
considered  under  their  respective  headings.  Podalic  version  may 
be  performed  either  by  the  combined  internal  and  external, 
otherwise  called  the  bipolar,  or  by  the  internal  method. 

The  combined  internal  and  external  method  for  podalic  as  well 
as  for  cephalic  version,  as  it  is  now  generally  carried  out,  was  first 

described  by  Dr.  Braxton 
Hicks.  Priority  has  been 
claimed  for  Dr.  Wright  of 
Cincinnati,  who  also  recom- 
mended the  combined  use  of 
two  hands,  but  his  method 
was  not  precisely  the  same. 

Bipolar  Version  in  Head 
Presentation. —  The  essential 
principle  of  the  method  con- 
sists in  the  use  of  the  internal 
hand  to  push  away  from  the 
OS  that  pole  of  the  trunk  of 
the  foetus  (in  shoulder  presen- 
tations), or  of  the  whole  foetus 
(in  head  presentations),  which 
is  occupying  it,  and  of  the 
external  hand  to  bring  down 
the  opposite  pole  into  the  os. 
Its  great  merit  is  that  it  can 
be  employed  at  an  early  stage 
of  labour,  when  the  os  is  only 
enough  dilated  to  admit  two 
fingers,  and  that  it  avoids  the  risk  to  the  mother  which  is  incurred 
by  forcibly  dilating  the  cervix  in  order  to  introduce  the  hand  into 
the  uterus.  For  its  performance,  it  is  essential  that  the  uterus 
should  be  so  relaxed  as  to  allow  the  foetus  to  move  readily,  and 
therefore  that  the  liquor  amnii  shall  not  have  drained  away  so 
completely  that  its  walls  have  closely  clasped  the  foetus.  When 
the  membranes  are  still  intact,  the  foetus  can  generally  be  rotated 
with  surprising  ease. 

Ancesthesia. — In  all  cases  of  version,  there  is  nothing  which 
facilitates  the  operation  so  much  as  complete  anaesthesia,  and  a 
comparatively  inexperienced  operator  will  find  it  especially  valuable. 


Jb'iG.  125. 


-First  stage  of  bipolar  version. 
(After  R.  Barnes.) 


Version.  867 

Chloroform  has  some  advantages  over  other  anaesthetics,  since, 
when  given  fully,  it  relaxes  the  uterus  more  completely.  There  is 
also  less  risk  attending  its  use  in  puerperal  women  than  in  average 
patients,  as  has  already  been  explained.  The  angesthetic  should  be 
given  to  the  full  surgical  degree,  so  that  the  voluntary  muscles  are 
relaxed,  and  the  uterus  is  rendered  as  flaccid  as  possible.  If 
possible,  there  should  be  an  assistant  to  administer  the  anesthetic. 
If  it  is  impossible  to  obtain  a  skilled  assistant,  the  operator  may 
first  place  the  patient  fully  under  its  influence,  and  then  rapidly 
perform  the  version  before 
she  recovers  sensation.  An 
anaesthetic  is  not,  however, 
absolutely  essential  for  the 
operation,  especially  if  the 
operator  is  dexterous,  and 
the  vagina  wide  enough  to 
admit  the  hand  easily. 

Position  of  the  Patient, 
and  Choice  of  Hand  to  he 
introduced. — In  this  country 
the  patient  is  usually  placed 
on  her  side  in.  the  ordinary 
obstetric  position.  If  the 
left  hand  is  used  internally, 
it  will  be  found  advantageous 
to  place  the  patient  upon  the 
right  side,  and  if  the  right 
hand  be  used  internally, 
upon  the  left  side.  The  hips 
should  be  brought  to  the  edge 
of  the  bed,  the  trunk  placed 
transversely,  and  the  thighs  bent  up  toward  the  abdomen.  The  right 
thigh  should  be  held  by  the  nurse  or  other  assistant,  so  that  the 
left  arm  may  reach  the  abdomen  by  passing  above  it.  The  right 
hand  should  be  introduced  into  the  vagina  as  a  rule,  and  the  left 
hand  should  be  placed  on  the  abdomen.  If,  for  any  reason,  as,  for 
instance,  on  account  of  a  cut  finger,  the  operator  prefers  to  intro- 
duce his  left  hand,  he  can  do  so  with  equal  advantage  by  placing 
the  patient  on  her  right  side  instead  of  on  her  left.  If  the  bed  is 
low,  the  operator  will  find  it  most  convenient  to  sit  down  opposite 
the  hips. 

Some  may  prefer  to  place  the  patient  in  the  lithotomy  position. 
The  operator  then  stands  or  sits  betweeii  the  thighs,  which  are  both 

55—2 


Fig.  426.— Second  part  of  first  stage  of 
Vjipolar  version. 


868 


The  Practice  of    Midwifery. 


supported  by  assistants  or  by  a  Clooer's  cratch.  Either  hand  may 
be  introduced.  It  is  better  to  choose  the  hand  so  that  its  flexor 
surface  will  correspond  to  the  abdominal  surface  of  the  foetus  when 
it  is  introduced.  Thus  the  right  hand  should  be  chosen  if  the 
abdomen  of  the  foetus  is  directed  toward  the  operator's  right  side, 
and  vice  versa. 

Time  for  operating. — It  is  of  great  importance  that  the  version 
should  be  performed  before  the  rupture  of  the  membranes.  If 
the  liquor  amnii  has  escaj^ed  at  all,  it  is  more  difficult,  and  it  is 

rarely  possible  to  turn  by  the 
bipolar  method  when  the 
membranes  have  been  rup- 
tured long.  A  dilatation  of 
the  cervix  sufficient  to  admit 
two  fingers  is  sufficient,  but 
it  is  easier  to  bring  the  leg 
through  the  os  if    a  some- 


what   greater  size  than  this 
has  been  reached. 

Method  of  operating.  — 
First  of  all,  the  exact 
position  of  the  foetus  must 
be  determined.  This  is  to 
be  done  by  abdominal  palpa- 
tion and  by  feeling  the 
sutures  and  fontanelles.  If 
any  doubt  whatever  exists, 
a  final  determination  must 
be  made  after  the  left  hand 
is  introduced  into  the  vagina,  by  feeling  an  ear,  or  by  recognising 
the  orbits,  nose,  or  face. 

The  vulva,  and  if  necessary  the  vagina,  having  been  cleansed  and 
disinfected,  the  dorsal  surface  of  the  hand  and  the  whole  of  the 
wrist,  covered  with  a  rubber  glove,  should  be  well  lubricated  with 
an  antiseptic  lubricant,  such  as  lanocyllin,  having  first  been  dis- 
infected with  perchloride  of  mercury  1  in  1,000.  The  hand  is  then 
passed  into  the  vagina  sufficiently  far  to  allow  two  fingers  to  be 
passed  their  full  length  through  the  cervix.  The  operation  is 
generally  easier  if  the  whole  hand  is  passed  into  the  vagina,  but  this 
is  not  always  absolutely  necessary.  If  the  cervix  lies  low,  a 
dexterous  operator  may  turn  by  passing  four  fingers  only  into  the 
vagina,  keeping  the  thumb  outside. 

First  Stage. — One  or  two  fingers  are  passed  through  the  cervix, 


Fig.  427. — Second  part  of  first  stage  of  bipolar 
version,  when  head  becomes  extended. 
(After  R.  Barnes.) 


Version. 


869 


and  rested  upon  the  presenting  part  of  the  head,  while  the  external 
hand  is  placed  upon  the  abdomen,  over  the  breech.  The  fingers 
then  push  the  head  upwards 
and  in  the  direction  of  the 
occiput  (see  Fig.  425,  p.  866). 
The  reason  for  this  is  that, 
if  the  head  were  pushed  in 
any  other  direction,  the  back 
or  side  of  the  foetus  would 
come  down  over  the  os,  and 
not  the  knees,  which  always 
lie  in  front  of  the  abdomen. 
As  the  fingers  push  the  head 
up,  the  external  hand  pushes 
the  breech  downwards  and  in 
the  direction  of  the  abdomen 
of  the  fcetus  (see  Fig.  425). 
The  pressure  is  to  be  con- 
tinued until  the  head  has 
receded  as  far  as  the  fingers 
can  reach  to  push  it  (see 
Fig.  426,  p.  867). 

Second  Stage. — As  the  head  thus  recedes,  the   foetus  generally 
preserves  its  attitude  of  general  flexion,  provided  that  a  good  deal 


Fig.  428. — Second  stage  of  bipolar  version. 


Fig.  429. — Commencement  of  tliird  stage  of  bipolar  version. 
(After  R.  Barnes.) 


of  liquor  amnii  is  still  retained,  and  the  limbs  are  the  next  parts 
which  the  internal  fingers  are  able  to  touch.     In  this  case  the 


870  The   Practice  of   Midwifery. 

second  stage  of  version  is  that  the  external  hand  continues  to  press 
down  the  hreech  toward  the  brim,  and  so  brings  the  knees  within 
reach  of  the  internal  finger,  which  secures  one  of  them  (Fig.  428, 
p.  869).  If,  however,  but  little  liquor  amnii  remains,  and  the  uterus 
envelops  the  foetus  more  closely,  the  head  may  become  extended  as 
it  is  pushed  away  by  the  fingers,  and  the  shoulder  or  chest  may  be 
felt  over  the  os  by  the  internal  fingers.  In  this  case  there  is  an 
intermediate  stage  in  which  the  shoulder  or  chest  is  pushed  by  the 
internal  fingers  in  the  direction  of  the  head,  the   external  hand 


Fig.  430. — Second  part  of  third  stage  of  bipolar  version.     (After  R.  Barnes.) 

continuing  to  press  the  breech  in  the  opposite  direction  and  down- 
wards (Fig.  427,  p.  868).  The  knee  is  distinguished  from  the  elbow 
by  its  pointing  towards  the  head,  and  not  away  from  it  (see  Fig.  427). 
As  soon  as  a  knee  is  felt,  the  membranes  are  to  be  ruptured  at 
this  point,  if  they  have  not  been  ruptured  already,  and  the  index 
finger  hooked  into  the  flexure  of  the  knee. 

Third  Stage. — As  soon  as  the  knee  is  firmly  secured  by  the 
finger,  the  external  hand  is  transferred  from  the  breech,  and 
placed  on  the  other  side  of  the  abdomen  over  the  head,  so  as  to 
push  the  head  up  towards  the  fundus  while  the  finger  draws  the 
knee  through  the  os  (Fig.  429).  When  the  knee  has  been  brought 
through  the  os  into  the  vagina  the  foot  should  be  brought  down, 


Version.  871 

so  that  the  operator,  by  feeling  the  heel,  may  assure  himself 
positively  that  he  has  secured  a  leg  and  not  an  arm  (Fig.  430). 

Traction  should  be  made  upon  the  leg,  until  the  greater  part 
of  the  thigh  has  passed  through  the  os,  and  the  half-breech  is 
beginning  to  enter  it.  This  will  bring  the  foot  outside  the  vulva. 
If  this  is  not  done,  and  the  leg  only  passes  through  the  os  as  far 
as  the  knee,  the  breech  may  remain  at  some  distance  from  the  os, 
the  long  axis  of  the  foetus  may  still  be  diagonal  or  nearly  trans- 
verse, and  the  progress  of  labour  is  liable  to  be  arrested.  When 
the  half-breech  is  once  brought  fully  into  the  os,  the  head  is  sure 
to  rise  to  the  fundus.  It  will  be  observed  that  the  action  of  the 
two  hands  is  strictly  bipolar  in  the  first  and  third  stages,  but  not 
in  the  second,  in  which  the  right  hand  presses  down  the  breech  for 
the  fingers  of  the  left  to  seize  the  knee. 

In  some  cases,  especially  when  liquor  amnii  is  abundant,  the 
foetus  is  so  very  mobile,  and  rotates  in  any  direction  so  easily,  that 
it  is  difficult  to  catch  a  knee.  If  the  foot  can  be  touched  before 
the  knee,  and  positively  identified  as  a  foot,  by  feeling  the  heel,  it 
may  be  caught  between  the  index  and  middle  fingers,  and  brought 
through  the  os.  Otherwise  it  is  better  to  rupture  the  membranes, 
and  then  seek  the  knee  or  foot,  which  will  be  brought  nearer  to 
the  OS,  and  will  be  less  mobile,  as  the  liquor  amnii  escapes.  The 
presence  of  the  hand  and  wrist  in  the  vagina  generally  prevents 
any  too  sudden  and  complete  escape  of  the  liquor  amnii.  Some- 
times the  long  axis  of  the  foetus  may  have  become  completely 
turned  round,  so  as  to  produce  a  breech  presentation,  before  the  leg 
is  seized. 

Choice  of  the  Leg  to  Seize. — When  version  is  performed  in  head 
presentations,  it  generally  makes  no  difference  which  leg  is  seized, 
and  therefore  the  knee  or  foot  which  comes  first  may  be  taken. 
There  is,  however,  one  exception  to  this  rule.  When  version  is 
performed  on  account  of  a  flattened  pelvis,  and  it  has  been  made 
out  that  there  is  more  room  on  one  side  of  the  pelvis  than  on  the 
other,  on  account  of  greater  width  of  the  sacral  wing  on  one  side, 
or  any  other  reason,  it  is  desirable  to  bring  the  occiput  toward  the 
wider  side.  Fig.  869  (p.  744)  shows  a  pelvis  of  this  kind,  and  it 
will  be  obvious  from  this  figure  how  it  is  that  the  head  adapts 
itself  better  to  the  pelvis  when  the  biparietal  diameter  is  on  the 
wider  side.  Since  the  leg  which  is  brought  down  always  eventually 
rotates  forward,  the  ol^ject  may  be  gained  by  seizing  the  leg  which 
it  is  desired  to  bring  to  the  front.  Thus,  if  the  left  side  of  the 
pelvis  is  the  widest  (as  in  Fig.  369),  the  left  leg  should  be  seized, 
and  vice  versa. 


872 


The  Practice  of   Midwifery. 


As  it  is  difficult  to  select  the  leg  when  only  one  or  two  fingers 
are  passed  through  the  os  uteri,  it  is  better  to  wait,  in  such  eases,  for 
a  somewhat  greater  dilatation  of  the  os  before  undertaking  version. 
The  hand  may  then  be  passed  through  the  os  to  select  the  leg,  if 
it  cannot  otherwise  be  made  out  which  is  right  and  which  is  left. 


Bipolar     Version     in     Shoulder    Presentations.  —  Bipolar 
version  is  not  so  often  available  in  shoulder  as  in  head  presenta- 


FiG.  431. — Internal  version  in  head  presentation.     Introduction  of  left  hand 
into  uterus,  patient  on  right  side.     (Modified  from  Nagel.) 

tions  ;  for,  if  the  membranes  are  intact,  it  is  generally  right  to 
attempt  cephalic  version,  and,  after  their  rupture,  the  liquor 
amnii  quickly  drains  away,  and  the  uterus  grasps  the  foetus  too 
closely  to  allow  it  to  be  turned  in  this  manner.  In  all  cases, 
however,  in  which  the  membranes  have  not  been  long  ruptured, 
the  bipolar  method  may  be  attempted  in  the  first  instance  without 
any  disadvantage ;  for  if  the  shoulder  cannot  be  made  to  recede  by 
pressure  with  the  fingers  passed  through  the  cervix,  it  is  easy, 
provided  that  the  cervix  is  sufficiently  dilated,  to  pass  the  hand  on 
into  the  uterus,  without  withdrawing  it  from  the  vagina,  and  seek 
the  knee  or  foot. 


Version.  873 

The  two  poles  which  have  now  to  be  regarded  are,  in  the  first 
instance,  not  the  poles  of  the  whole  foetus,  namely,  the  breech  and 
head,  but  the  poles  of  the  trunk  apart  from  the  head — that  is  to 
say,  the  breech  and  shoulder.  The  position  is  similar  to  that  in 
the  exceptional  stage  of  bipolar  version  shown  in  Fig.  427,  p.  868. 
The  fingers  passed  through  the  cervix  first  push  the  shoulder 
upwards,  in  the  direction  of  the  head  and  somewhat  toward  the 
back  of  the  foetus,  so  that  its  abdominal  surface  is  brought  over 
the  OS.  At  the  same  time  the  external  hand  is  used  to  press 
down  the  breech  in  the  direction  of  the  os.  If  the  shoulder  can 
be  made  to  recede,  the  knee  is  sought  for  and  hooked  by  the 
finger  in  the  same  way  as  in  head  presentations.  As  soon  as  the 
knee  is  thus  secured,  the  external  hand  is  transferred  from  the 
breech  to  the  head,  and  presses  the  head  up  toward  the  fundus,  as 
in  Fig.  429,  p.  869.  At  this  stage,  therefore,  the  two  forces  are 
applied  to  the  poles  of  the  entire  foetus.  The  whole  proceeding  is, 
of  course,  comparatively  easy  if  the  liquor  amnii  is  still  intact. 

If  the  shoulder  cannot  easily  be  made  to  recede  by  the  direct 
pressure  of  the  fingers,  and  the  arm  is  prolapsed  in  the  vagina,  it 
is  sometimes  advantageous  to  grasp  the  humerus  with  the  hand  in 
the  vagina,  and  use  it  as  a  kind  of  handle  to  push  the  shoulder  in 
the  required  direction. 

Internal  Version  in  Head  Presentations. — Internal  version 
has  been  employed  so  much  more  extensively  than  any  other  kind 
of  version,  that  it  is  generally  regarded  as  version  jjar  excellence. 
The  object  is  to  seize  one  leg,  and  bring  it  through  the  os  into  the 
vagina.  Then,  by  traction  exerted  on  the  breech  through  the 
medium  of  this  leg,  the  foetus  is  made  to  rotate ;  whatever  part 
was  previously  presenting  is  thereby  caused  to  recede,  and  the 
half -breech  is  brought  into  the  os.  The  reason  for  bringing  down 
one  leg  only  and  not  both  legs  is  that  the  half-breech  forms  a  better 
dilator  for  the  cervix  and  other  soft  parts  than  the  two  thighs  side 
by  side,  and  therefore  there  is  less  risk  of  the  after-coming  head 
being  delayed,  and  the  child's  life  lost  in  consequence.  If  the  child 
is  previously  dead,  in  the  case  of  shoulder  presentation,  or  if  the 
operation  proves  difficult  to  perform,  there  is  sometimes  an 
advantage  in  bringing  down  both  legs. 

Choice  of  Hand  to  introduce. — As  a  general  rule,  the  patient  may 
be  placed  on  the  right  side,  and  the  left  hand  used  for  all  cases. 
Whatever  be  the  position  of  the  ffjetus,  the  left  hand  can,  as  a  rule, 
reach  its  abdominal  surface,  and  so  find  the  knees;  for  the  abdomen 
never  looks  directly  forward,  even  in  occipito- posterior  positions  of 


874 


The   Practice  of   Midwifery. 


the  vertex.  By  supinating  the  forearm,  the  hand  may  he  brought 
to  reach  the  right  side  of  the  pelvis  ;  by  pronating  it,  to  reach  the 
left  side.  By  this  means  the  posterior  leg  at  any  rate  can  be 
reached  by  the  left  hand,  even  in  occipito-posterior  positions  of 
the  foetus.  In  occipito-anterior  positions  the  left  hand  has  not  to 
diverge  far  from  the  posterior  wall  of  the  genital  canal. 

The  primary  choice  of  the  hand  to  introduce  is  not  a  matter  of 
great  consequence,  and  different  authorities  have  given  different 

rules  on  the  subject.  If  the 
patient  is  placed  on  her 
back,  the  right  hand  may  be 
chosen  if  the  abdomen  of 
the  child  is  directed  toward 
the  right  of  the  operator  (see 
Fig.  432),  and  vice  versa. 

Preparations.  —  In  cases 
where  internal  version  is 
necessary,  complete  anaes- 
thesia is  even  more  impor- 
tant than  in  those  in  which 
it  is  possible  to  perform 
bipolar  version,  in  order  to 
facilitate  the  operation  by 
securing  the  greatest  possible 
relaxation  of  the  uterus. 
The  patient's  upper  knee  is 
to  be  raised,  as  in  the  former 
case,  that  the  external  hand 
may  have  access  to  the 
abdomen,  and  make  counter- 
pressure  on  the  breech  to 
support  it,  even  if  it  is  not 
able  actually  to  bring  it 
nearer  to  the  internal  hand. 
Not  only  the  dorsal  surface  of  the  hand,  but  the  whole  of  the 
forearm  should  be  thoroughly  lubricated,  a  rubber  glove  being  of 
course  worn. 

Method  of  operating. — The  whole  hand  is  gently  and  slowly 
passed  into  the  vagina,  the  fingers  being  held  together  in  the  form 
of  a  cone.  If  the  cervix  is  not  dilated  enough  to  allow  the  hand 
to  pass,  it  must  be  gradually  stretched  by  the  fingers  pressed  into 
it  in  the  same  conical  form,  until  there  is  room  for  the  hand  to 
pass  it.    The  exact  position  of  the  foetus  should  have  been  previously 


Fig.  432.  —  Internal  version  in  head 
presentation.  Seizing  the  leg.  (After 
Tyler  Smith.) 


Version.  875 

made  out.  The  operator  must  now  verify  his  diagnosis,  as  the 
hand  passes  into  the  uterus,  by  feehng  the  face.  The  direction  of 
the  face  will  guide  the  hand  toward  the  abdominal  surface  of  the 
foetus,  up  which  it  ought  to  pass.  To  make  room  for  the  hand  to 
pass,  the  head  must  be  pushed  out  of  the  way.  In  doing  this  the 
operator  should  carry  out  in  some  degree  the  principle  of  bipolar 
version,  even  though  it  is  impossible  to  do  so  fully.  That  is  to  say, 
he  should  push  the  head  in  the  direction  of  the  occiput,  in  order  to 
bring  the  abdominal  surface  of  the  foetus  toward  the  internal  hand, 
and  should  at  the  same  time  make  counter-pressure  on  the  breech 
with  the  external  hand  (Fig.  431). 

Seizing  the  Knee. — The  hand  and  arm  should  be  gradually  passed 
up  toward  the  fundus  in  the  absence  of  a  pain,  the  external  hand 
still  making  counter-pressure  over  the  uterus,  until  the  hand 
reaches  the  child's  abdomen.  If  unruptured,  the  membranes 
should  be  ruptured  so  that  the  hand  may  be  passed  into  the 
amniotic  cavity  and  be  separated  from  the  uterine  wall  by  the 
membranes.  If  a  pain  comes  on  during  the  operation,  the  hand 
must  be  allowed  to  lie  flat  against  the  uterine  wall  until  it  has 
passed  off.  As  the  hand  passes  the  head,  it  sometimes  happens 
that  a  ring  projecting  inwards,  formed  by  contraction  of  the 
internal  os,  is  detected  above  the  head.  In  such  case,  the  attempt 
to  turn  should  be  given  up ;  for  this  condition  implies  that  the 
cervix  has  undergone  dangerous  thinning  through  retraction  of  the 
body  of  the  uterus  in  prolonged  labour,  and  that  the  uterus  has 
closed  tightly  round  the  foetus  after  the  escape  of  the  liquor  amnii. 
If  an  attempt  is  made  to  force  the  head  back  over  the  projecting 
ring,  there  is  a  great  risk  of  causing  rupture. 

Most  of  the  older  authors  recommended  that  a  foot  should  be 
seized.  The  knee  is  preferable,  for  two  reasons.  In  the  first  place, 
it  is  nearer,  and  generally  is  reached  first.  Secondly,  it  can  be 
secured  by  hooking  the  forefinger  into  the  flexure  of  the  joint. 
The  foot  cannot  be  held  securely  without  the  use  of  the  thumb, 
and,  when  the  thumb  is  used,  the  closed  fist  occupies  more  space, 
and  cannot  therefore  be  so  easily  withdrawn.  The  knees  will  be 
found  near  the  elbows,  and  not  far  from  the  level  of  the  umbilicus. 
A  knee  is  distinguished  from  an  elbow — first,  by  its  being  broader, 
and  not  having  the  sharp  projection  of  the  olecranon ;  secondly, 
by  its  pointing  toward  the  head,  while  the  elbow  points  away  from 
it.  In  case  of  any  doubt  being  felt,  the  finger  should  be  passed  up 
the  limb  to  feel  the  breech,  or,  better,  the  foot,  which  can  be  verified 
by  the  heel.  In  general,  whichever  leg  comes  first  should  be  taken. 
It  is  only  necessary  to  make  a  selection  in  the  exceptional  case 


876 


The  Practice  of   Midwifery. 


before  mentioned  (see  p.  871),  in  which  it  is  desired  to  bring  the 
occiput  into  the  wider  side  of  an  unequal  pelvis.  If  the  foot 
happens  to  be  reached  more  readily  than  the  knee,  it  may  be 
taken  instead. 

The  forefinger,  having  secured  the  knee,  draws  it  downwards 
through  the  os  uteri,  and  thereby  effects  rotation  of  the  foetus  and 
recession  of  the  head.  As  soon  as  the  leg  is  in  the  vagina,  the 
foot  is  brought  down.  Traction  is  then  to  be  made  upon  the  leg, 
until  the  half-breech  has  fully  entered  the  os,  and  the  head  has 
ascended  to  the  fundus.    The  ascent  of  the  head,  in  the  later  stage, 

may  be  assisted  by  pressure 
upwards  with  the  external 
hand,  as  in  Fig.  430,  p.  870. 
If  the  foetus  cannot  be 
made  to  rotate  by  traction 
upon  the  knee  or  foot,  the 
expedients  may  be  tried 
which  will  shortly  be 
described  as  available  in 
difficult  versions  for  shoulder 
presentation.  But,  if  resist- 
ance is  great,  it  is  generally 
better  not  to  persevere  with 
the  version,  since,  in  head 
presentation,  it  is  usually 
undertaken  only  for  the 
sake  of  the  foetus,  which  is 
very  likely  to  be  dead. 


Fig.  433. — Version  by  leg  diagonally  opposite 
to  presenting  shoulder.  (After  Tyler 
Smith.) 


Internal  Version  in 
Shoulder  Presentations. 
— The  left  hand  may  be  introduced,  as  a  rule,  in  all  cases,  as  in 
the  other  forms  of  version,  the  patient  being  placed  on  the  right 
side ;  for  since,  even  in  dorso-posterior  positions,  the  abdomen  does 
not  look  exactly  forwards,  but  is  inclined  to  one  side,  the  hand  can 
always  be  carried  far  enough  round  one  side  or  other  of  the  pelvis 
to  reach  the  posterior  or  lower  knee.  Some  authors,  however, 
recommend  the  use  of  the  left  hand  in  dorso-anterior  positions,  the 
right  hand  in  dorso-posterior  positions  (see  Fig.  433),  the  patient 
being  placed  upon  the  side  opposite  to  the  hand  used.  If  tbe 
patient  is  placed  on  her  back,  the  right  hand  may  be  used  if  the 
child's  abdomen  looks  towards  the  mother's  left,  and  conversely 
(see  Fig.  432,  p.  874). 


Version. 


877 


Choice  of  Leg  to  seize. — In  general  it  is  preferable  to  seize  the 
lower  leg,  or  that  on  the  same  side  as  the  presenting  shoulder. 
This  is  always  nearer  and  easier  to  reach,  in  some  cases  very  much 
easier,  than  the  upper  leg,  or  that  diagonally  opposite  to  the 
presenting  shoulder.  If  it  is  seized,  the  nearest  part  of  the  half- 
breech  is  brought  to  the  os  uteri  by  the  shortest  path,  and  the 
foetus  is  turned  in  the  bilateral  plane  of  its  trunk — that  is  to  say, 


Fig.  434.  —  Internal  version  in  transverse  presentation,  dorso-anterior 
position.  Introduction  of  right  hand  into  uterus,  patient  on  left  side. 
(Modified  from  Nagel.) 


round  an  antero-posterior  axis  passing  through  the  centre  of  the 
trunk.  This  is  the  simplest  kind  of  version  which  can  effect 
the  desired  object,  since  no  complete  rotation  of  the  long  axis 
of  the  ffjetus  is  necessary.  Its  position  being  already  oblique,  it 
is  sufficient  to  turn  it  through  an  angle  of  not  much  more  than 
lOO'^  to  bring  the  half-breech  into  the  os.  The  back  of  the  foetus, 
which  is  generally  anterior  to  begin  with,  remains  anterior  after 
the  version — that  is  to  say,  it  remains  in  the  most  favourable 
position. 


878 


The   Practice  of   Midwifery. 


Some  authorities  recommend  turning  by  the  upper  leg  in  dorso- 
posterior  cases,  in  order  to  convert  them  into  dorso-anterior,  and 
so  facilitate  the  expulsion  of  the  fcetal  pelvis  through  the  pelvic 
outlet.  This,  however,  is  of  less  importance  than  rendering  the 
version  itself  as  easy  as  possible;  since  the  rotation  of  the  posterior 
hip  forward,  when  the  posterior  leg  is  extended,  only  involves  a 
slight  delay.-^ 

Application  of  Noose  to  Prolapsed  Arm. — There  is  an  advantage 


Fig.  435. — Internal  version  in  transverse  presentation.     Seizing  the  lower 
foot.     (Modified  from  Nagel.) 

to  be  gained  by  placing  a  noose  of  tape  round  the  wrist  of  the 
prolapsed  arm,  and  even  in  drawing  the  arm  down  for  this  jDurpose 
if  it  is  easily  reached.  This  will  give  the  operator  complete  control 
over  this  arm,  and  he  will  always  be  able  to  prevent  it  becoming 
extended  above  the  head,  and  so  delaying  the  passage  of  the  foetus 
through  the  brim.  The  advantage  of  the  expedient  is  sfcill  greater 
if  the  version  is  made  by  the  leg  belonging  to  the  same  side  as  the 

1  For  a  full  discussion  of  the  subject,  see  a  paper  by  the  author  "  On  the  Choice  of 
the  Leg  in  Version,"  Trans.  Obst.  Soc.  London,  1877,  Vol.  XIX.,  p.  239. 


Version. 


879 


presenting  shoulder ;  for  since  the  leg  which  is  brought  down 
always  rotates  eventually  to  the  front,  the  arm  which  is  commanded 
will  always  in  that  case  be  the  anterior  arm.  Now  the  posterior 
arm  is  always  much  more  easy  to  bring  down  than  the  anterior ; 
for  as  the  fcetus  is  drawn  in  the  direction  of  the  pelvic  outlet,  the 
posterior  shoulder,  and  therefore  the  posterior  arm,  are  much  lower 
in  reference  to  the  pelvic  brim  than  the  anterior,  and  more  easily 
reached  in  consequence  (see  Fig.  401,  p.  816).  Also  there  is  more 
room  posteriorly  for  the  hand  to  pass  up.  Hence  if  the  operator 
has  comroand  of  the  anterior  arm  by  means  of  the  noose,  he  will 
be  able  to  deal  with  the  pos- 
terior arm  without  difficulty, 
and  the  child's  life  is  not 
likely  to  be  lost  through  the 
extension  of  the  arms. 

Method  of  operating. — The 
hand  is  introduced  through 
the  OS  uteri  as  in  version  per- 
formed in  head  presentation. 
The  exact  position  of  the 
foetus  should  have  been  pre- 
viously made  out.  The  hand, 
as  it  passes  into  the  uterus, 
verifies  the  diagnosis  by 
making  out  the  axilla,  and 
the  direction  of  the  neck  and 
head.  In  pushing  the 
shoulder  aside  in  order  to 
make  room  for  the  hand  to 
pass,  the  operator  should  push 
it  in  the  direction  of  the  head 
and  toward  the  back  of  the  foetus,  as  well  as  upward,  so  as  to  bring 
the  abdomen  nearer  to  his  hand.  At  the  same  time  the  external 
hand  makes  counter-pressure  upon  the  breech,  so  as  to  diminish  the 
strain  upon  the  uterine  attachments,  and  also  to  bring  the  breech, 
if  possible,  somewhat  nearer  to  the  os.  The  hand  is  then  passed 
on  from  the  shoulder  to  the  front  of  the  chest,  and  thence  to  the 
abdomen,  and  there  seeks  for  the  lower  knee,  or  that  belonging  to 
the  same  side  as  the  presenting  shoulder  (Fig.  436).  The  operator 
distinguishes  a  knee  from  an  elbow  in  the  manner  already  described 
(see  p.  870),  and  one  knee  from  the  other  l)y  tracing  the  limb  up 
to  the  breech  or  foot.  The  index  linger  is  hooked  into  the  Hexure 
of  the  knee  and  draws  it  through  the  os.     The  external  hand  may 


Fig.  436. — Version  by  the  nearer  leg,  or  that 
corresponding  to  the  presenting  shoulder. 
Noose  placed  upon  prolapsed  arm. 


88o 


The   Practice  of   Midwifery. 


then  assist  the  rotation  of  the  foetus  by  pushing  the  head  up 
toward  the  fundus.  As.  soon  as  the  leg  is  in  the  vagina  the  foot 
is  brought  down,  and  traction  made  upon  it  until  the  half -breech 
has  entered  the  os  and  the  foot  is  outside  the  vulva.  The  rotation 
of  the-  foetus  will  then  be  complete  (Fig.  437).  In  dorso-posterior 
positions,  the  hand,  on  reaching  the  back  of  the  shoulder,  should  be 
carried  round  toward  the  side  of  the  pelvis  opposite  to  that  where 


Fig.  437. — Internal  version.     Leg  drawn  down  into  the  vagina,  head  pushed 
up  to  the  fundus.     (Modified  from  Nagel.) 

the  head  is  situated.  Passing  along  the  side  of  the  foetus,  it  is 
thereby  guided  to  the  thigh  and  knee  corresponding  to  the  presenting 
shoulder.  If  the  one  hand  cannot  reach  the  knee  or  foot  in  this 
way,  it  should  be  withdrawn  and  the  other  hand  introduced. 

Version  in  Impacted  Shoulder  Presentation. — When  the  membranes 
have  long  been  ruptured,  and  the  uterus  is  closely  contracted 
around  the  child,  there  may  be  difficulty  in  getting  the  child  to 
revolve  after  the  leg  has  been  seized.  Under  these  circumstances 
it  is  first  of  all  important  to  make  sure  that  chloroform  is  given  to 
the  full  surgical  degree,  to  secure  the  greatest  possible  amount  of 


Version.  .  88 1 

relaxation  of  the  uterus.  Next  there  are  two  exj)edients  which  will 
almost  always  overcome  the  difficulty.  The  first  is  to  find  means 
of  applying  more  powerful  traction  to  the  leg  than  can  easily  be 
exercised  with  the  finger  ;  the  second  is  so  to  apply  this  traction 
that  room  is  left  in  the  vagina  for  the  hand  to  push  up  the 
shoulder,  and  thus  bring  two  forces  to  bear  simultaneously  on 
the  opposite  poles  of  the  trunk.  The  best  means  of  making  traction 
on  the  leg  is  the  use  of  a  small  blunt  hook,  as  recommended 
by  Dr.  Braxton  Hicks.  The  stem  of  the  instrument  is  made  of 
sufficiently  soft  metal  to  allow  it  to  be  bent,  if  necessary,  to  suit 
the  curve  of  the  genital  canal,  or  the  direction  in  which  it  has  to  be 
passed.  The  diameter  of  the  hook  is  about  one  inch.  The  handle 
of  the  hook  is  held  in  the  right  hand.  As  the  left  forefinger  holds 
the  knee,  the  hook  is  passed  up  under  cover  of  the  arm  and  hand, 
with  the  flat  side  against  the  foetus.  When  the  knee  is  reached 
the  handle  is  turned,  so  as  to  fix  the  hook  across  the  flexure  of  the 
knee,  the  point  being  directed  inwards.  The  finger  makes  sure 
that  the  point  of  tbe  hook  is  clear  of  the  knee  on  the  inner  side, 
so  as  not  to  injure  the  popliteal  space.  Very  powerful  traction  can 
then  be  made  upon  the  leg  with  the  right  hand.  The  left  hand 
may  be  used  to  prevent  the  leg  becoming  extended,  or  since  the 
stem  of  the  hook  occupies  scarcely  any  space  in  the  vagina,  the  left 
hand  may  be  used  to  push  up  the  shoulder,  while  the  right  hand 
draws  down  the  knee.  In  this  case  the  traction  of  the  hook  may 
sometimes  cause  extension  of  the  leg  and  descent  of  the  foot.  If 
this  happens,  it  will  be  necessary  to  remove  the  hook,  and  place  a 
noose  of  tape  over  the  foot. 

If  a  small  blunt  hook  of  the  kind  here  described  is  not  at  hand, 
the  foot  should  be  brought  down  as  low  as  possible,  a  noose  of 
rather  broad  tape  should  be  placed  over  it,  and  traction  made 
upon  the  tape  with  the  right  hand,  while  the  left  hand  jDushes  up 
the  shoulder.  If  the  fcetus  will  not  rotate  when  pressure  and 
traction  are  made  simultaneously,  it  sometimes  answers  better  to 
push  up  the  shoulder  with  one  hand,  and  pull  down  the  leg  with 
the  other,  alternately.  A  little  is  gained  at  each  repetition  of  this 
mancjeuvre.  Various  devices  have  been  suggested  to  facilitate  the 
application  of  the  noose  when  it  is  found  difficult  to  fix  it  over  the 
foot  with  the  fingers.  Most  instruments  for  this  purpose  consist 
essentially  of  a  long  rod  with  a  hole  at  the  end  of  convenient  size 
for  passing  a  loop  of  tape  through.  A  convenient  implement  is  a 
tube  of  soft  metal  about  sixteen  inches  long,  large  enough  to  allow 
a  loop  of  tape  to  be  passed  through  it.  The  loop  is  made  to  project 
at  the  end  of  the  tube,  is  passed  up  into  the  uterus  by  the  aid  of 
M.  56 


882  The   Practice  of   Midwifery. 

the  tube,  and  guided  over  the  foot  by  the  fingers  of  the  left  hand. 
The  tape  is  then  drawn  up  until  the  foot  is  held  firmly  enough,  but 
not  too  tightly,  against  the  end  of  the  tube.  The  ends  of  the  tape 
are  then  tied  over  a.  cross  piece  of  wood  at  the  lower  end  of  the 
tube,  and  tube  and  tape  together  used  for  traction. 

In  the  absence  of  such  a  noose-carrier,  a  loop  of  tape  may  be 
carried  up  and  passed  over  the  foot  by  means  of  a  funis  repositor, 
or  a  large  gum-elastic  catheter  with  stylet,  used  like  a  funis 
repositor.  When  the  loop  is  drawn  up  tight  enough,  the  tape 
and  catheter  are  held  together  side  by  side,  and  traction  made  with 
them. 

In  very  difiicult  cases  the  second  leg  should  be  brought  down, 
noosed,  if  necessary,  and  traction  should  be  made  on  both  legs 
together.  This  is  especially  useful  if  the  foetus  has  been  dead  for 
some  time,  and  is  macerated  and  softened,  for  under  such  circum- 
stances a  single  leg  may  sometimes  be  torn  away  from  the  trunk. 
If  the  half-breech  begins  to  enter  the  os,  and  the  shoulder  still 
will  not  recede,  the  plan  may  be  tried  of  making  traction  mainly  on 
the  leg  diagonally  opposite  to  the  presenting  shoulder,  in  order  to 
elevate  the  shoulder  by  rotating  the  foetus  on  its  longitudinal  axis, 
as  proposed  by  Sir  James  Simpson ;  for,  although  the  half-breech 
and  shoulder  of  the  same  side  cannot  generally  become  jammed 
together  in  the  os,  this  may  happen  if  the  foetus  has  been  long  dead, 
and  has  lost  all  tonicity. 

It  must  be  remembered  that  all  these  manoeuvres  are  extremely 
dangerous  when  the  uterus  is  tetanically  contracted,  and  great  care 
and  experience  are  required  to  employ  them  successfully.  In  all 
doubtful  cases  it  is,  as  a  rule,  better  not  to  attempt  them. 

The  treatment  to  be  adopted  if  version  is  found  altogether  impos- 
sible has  been  already  considered  (see  pp.  674 — 677). 


Chapter  XXXV. 

CRANIOTOMY  AND  EMBRYOTOMY. 

Undee  the  head  of  Craniotomy  are  generally  included,  not 
merely  the  perforation  of  the  head,  but  the  means  required  for 
extracting  it  after  perforation. 

Indications  for  the  Operation. — The  various  conditions 
calling  for  craniotomy  have  already  been  detailed.  The  chief  of 
them  are — great  disproportion  between  the  head  and  the  pelvis, 
obstruction  caused  by  tumours,  or  by  cancer  of  the  cervix  ;  in  rare 
cases  obstruction  due  to  rigidity  of  the  cervix,  inflammatory 
deposits  or  cicatrices ;  also  dangerous  conditions  of  the  mother, 
such  as  eclampsia,  calling  for  rapid  delivery,  when  the  use  of 
forceps  or  version  is  not  sufficient  to  meet  the  case,  and  Csesarean 
section  is  contraindicated. 

On  the  Continent  practice  has  been  influenced  by  the  dictum  of 
the  Komish  Church  that  it  is  not  lawful  to  destroy  the  fcetus  to 
diminish  the  risk,  or  even  to  save  the  life  of  the  mother.  In  this 
country  the  interest  of  the  mother  has  always  been  considered 
paramount.  The  operation,  however,  stands  on  a  different  footing 
when  the  foetus  is  dead  and  when  it  is  alive.  If  there  is  clear 
evidence  of  the  death  of  the  fcetus,  craniotomy  should  be  per- 
formed whenever  it  renders  extraction  in  any  degree  easier  or  less 
perilous  to  the  mother.  While  the  foetus  is  alive  the  operation  is 
only  justifiable  if  delay  or  attempts  to  extract  by  other  means 
involve  a  material  and  undoubted  increase  of  risk  to  the  mother. 
When  the  operation  has  once  been  decided  to  be  desirable,  it 
should  be  performed  without  delay.  To  wait  for  the  previous 
death  of  the  child  greatly  increases  the  danger  to  the  mother,  and 
gains  only  a  sentimental  benefit. 

Mortality. — In  cases  of  extreme  pelvic  contraction,  or  obstruc- 
tion by  tumours,  craniotomy  is  a  dangerous  operation,  as  already 
explained.  Thus  in  70  cases  of  pelves  having  a  conjugate  diameter 
under  2^  inches  Perry  records  a  mortality  of  38"5  per  cent,  (see 
p.  751).  In  the  easier  cases,  in  which  it  comes  into  competition  with 
extraction  by  forceps  or  version,  it  involves  little  risk  to  the  mother, 

56—2 


884 


The   Practice  of   Midwifery. 


provided  that  it  is  performed  early.  If  danger  arises,  it  is  generally- 
due  to  previous  delay,  or  to  attempts  to  extract  the  undiminished 
head. 

In  the  Guy's  Hospital  Charity  (1863—1875)  the  mortality  after 
craniotomy  amounted  to  6  out  of  18  cases,  or  33'3  per  cent.  But 
the  proportion  of  craniotomy  cases,  18  in  26,591  deliveries,  or 
0"7  per  1,000,  is  a  very  low  one,  showing  that  the  operation  was 
only  resorted  to  in  extreme  cases.  The  proportion  of  deaths  after 
craniotomy  per  1,000  deliveries  is  thus  only  0*23.     In  the  interval 


Fig.  438. — Oldham's  perforator. 


Fig.  439. — Simpson's  perforator. 


between  1833  and  1854,  in  which  craniotomy  cases  were  about 
five  times  as  frequent  in  the  Guy's  Hospital  Charity — namely 
35  per  1,000 — the  total  number  of  deaths  after  delivery  by  forceps, 
version  for  obstructed  labour,  or  craniotomy  per  1,000  deliveries 
was  0*57  per  1,000.  The  corresponding  proportion  was  0"50  per 
1,000  in  the  interval  1863 — 1875.  Thus  the  extensive  substitution 
of  extraction  by  forceps  or  version  for  craniotomy  was  associated 
with  rather  a  diminished  than  an  increased  mortality  to  the 
mothers.  In  the  ten  years  1875 — 1884  there  were  24  cases  of 
craniotomy  in  25,489  deliveries.  There  were  4  deaths,  or  16*6  per 
cent.,  including  one  case  in  which  the  uterus  was  ruptured  before 


Craniotomy  and    Embryotomy.  885 

the    craniotomy.     In  the  ten  years  1892 — 1901  there  were  3  deaths 
in  33  cases  of  embryotomy,  or  9  per  cent. 

Munro  Kerr^  records  83  cases  operated  upon  in  the  Glasgow 
Maternity  Hospital  from  1901  to  1906  with  8  deaths,  a  mortality 
of  12*6  per  cent.  In  most  of  the  fatal  cases,  however,  the  parturient 
canal  was  much  injured,  and  the  patients  infected  before  their  entry 
into  the  hospital.  Schauta^  records,  among  49,397  births  in  his 
clinique  in  the  years  1892 — 1906,  82  cases  of  craniotomy  on  the 
dead  child  with  5  deaths,  or  a  mortality  of  6  per  cent.,  and  76 
cases  of  craniotomy  on  the  living  child  with  1  death,  or  a  mortality 
of  1*3  per  cent. 

Instruments  for  Perforation. — The  perforators  chiefly  used 
in  this  country  are  modifications  of  the  original  scissors  of  Smellie. 
These  had  points  like  the  modern  perforator  (Fig.  438,  p.  884),  but 
handles  like  ordinary  scissors,  and  the  whole  instrument  was  less 
powerful.  The  best  forms  of  perforator  are  Oldham's  (Fig.  438) 
and  Simpson's  (Fig.  439).  With  the  former  the  hand,  placed 
between  the  handles  in  holding  the  instrument,  as  shown  in 
Fig.  440,  p.  886,  keeps  the  points  together.  With  the  latter  the 
palm  of  the  hand  is  pressed  against  the  spring,  which  joins  the  ends 
of  the  handles  and  keeps  the  points  from  separating.  Of  the  two, 
Oldham's  perforator  gives  the  more  powerful  hold.  The  points 
should  be  sufficiently  sharp  to  penetrate  the  head  readily,  yet  not 
so  sharp  as  easily  to  prick  the  fingers  or  the  vagina.  When  the 
points  are  closed,  the  handles  should  not  be  too  far  apart  to  allow 
them  to  be  brought  together  by  the  fingers  of  one  hand.  The 
point  of  Simpson's  perforator  is  sometimes  made  curved,  to  allow 
it  more  easily  to  be  placed  at  right  angles  to  the  head,  but  it  is 
preferable  to  have  the  point  in  the  line  of  the  handle,  in  which  line 
pressure  has  to  be  made. 

In  Germany  a  trephine  perforator  has  been  much  used.  The 
object  is  to  cut  a  clean  round  hole  out  of  the  skull,  so  that  the  hole 
is  not  likely  to  close,  or  fragments  of  bone  to  project.  It  cannot, 
however,  be  used  so  easily  and  quickly  as  the  English  perforator, 
and  has  the  great  disadvantage  that  it  cannot  conveniently  be  used 
to  perforate  the  after-coming  head.  Moreover,  it  is  not  found 
practically  that,  after  the  use  of  the  ordinary  perforator,  the  hole 
does  close  up,  or  angles  of  bone  do  project. 

Condition  of  Cervix. — It  is  not  absolutely  necessary  for  the 
operation  that  the  cervix  should  be  fully  dilated.     There  should, 

'  Munro  Kcir,  Operative  Midwifery,  1908,  p.  481. 

2  Schauta,  Jourri.  Obst.  and  Gyn.  Brit.  Emp.,  Vol.  XV.,  No.  .5,  p.  .S22. 


886 


The   Practice  of   Midwifery. 


however,  be  room  for  the  separation  of  the  points  of  the  perforator 
without  danger  of  lacerating  the  edges  of  the  cervix,  and  also  for 
the  introduction  of  instruments  for  the  subsequent  extraction  of 
the  foetus.  If  the  cervix  is  too  small  to  allow  this,  it  should  be 
previously  dilated,  either  by  the  hydrostatic  dilators,  or  by  the  hand 
introduced  in  a  conical  form,  with  the  aid  of  an  anaesthetic. 

Method     of    operating. — An     anaesthetic    is     not     absolutely 
necessary,  but  it  facilitates  the  operation,  and  spares  the  feelings 


Fig.  440. — Perforation  of  head. 


of  the  patient.  It  should  be  used,  at  any  rate,  in  all  difficult 
cases.  Bladder  and  rectum  should  first  be  emptied.  The  hips 
should  be  brought  quite  over  the  edge  of  the  bed ;  the  bed 
should  be  protected  by  a  mackintosh,  hanging  down  over  the 
edge,  and  a  footpan  should  be  at  hand  to  catch  the  evacuated 
brain  substance. 

The  spot  on  the  head  chosen  for  perforation  should  be  near  the 
centre  of  the  presenting  part,  as  far  away  as  possible  from  the 
margin  of  the  os  or  other  soft  parts.  The  perforation  should  be 
made  through  the  anterior  parietal  bone,  and  not  through  a  suture 


Craniotomy  and   Embryotomy.  887 

or  fontanelle ;  for  in  the  latter  case  the  bones  may  be  simply 
separated  and  not  broken  through,  and  may  close  together  again 
when  the  perforator  is  withdrawn,  not  leaving  a  sufficient  free 
opening  for  the  evacuation  of  the  brain  matter. 

The  left  hand  is  passed  into  the  vagina  so  that  the  fingers  rest 
upon  the  spot  to  be  perforated.  An  assistant  should  make  counter- 
pressure  over  the  uterus,  so  as  to  press  the  head  firmly  down  into 
the  brim  and  keep  it  steadily  fixed  there.  The  perforator  is  held 
in  the  right  hand,  in  the  manner  shown  in  Fig.  440,  the  palm  of 
the  hand  being  between  the  handles.  It  is  passed  up  to  the  head 
under  cover  of  the  left  hand,  the  point  being  kept  close  against 
the  hand.  As  soon  as  the  head  is  reached  the  handle  is  carried 
backward,  so  as  to  make  the  point  impinge  upon  the  head  in  as 
perpendicular  a  direction  as  possible.  The  point  is  forced  into 
the  head  by  a  combination  of  pressure  and  boring  or  screwing 
movement  until  the  bones  are  felt  to  yield.  The  perforator  is 
then  pushed  gently  on  until  the  shoulders,  which  terminate  the 
cutting  portion,  are  level  with  the  scalj).  The  handles  are  now 
approximated  by  the  thumb  and  fingers  of  the  right  hand,  so  as 
to  separate  the  points,  and  make  a  free  opening  in  the  skull.  The 
fingers  of  the  left  hand  are  meanwhile  kept  upon  the  blades,  at  the 
points  where  they  enter  the  scalp,  to  make  sure  that  the  soft  parts 
are  not  endangered.  The  points  are  then  closed  again,  the  instru- 
ment is  rotated  on  its  axis  through  a  right  angle,  and  the  points 
are  again  separated  in  a  direction  at  right  angles  to  the  first.  In 
the  case  of  a  greatly  flattened  pelvis,  it  is  better  to  choose  for  the 
two  directions  the  two  oblique  diameters  of  the  pelvis,  since  these 
afford  more  room  than  the  conjugate  diameter. 

The  skull  having  been  thus  freely  opened,  the  perforator  is 
closed  and  passed  on  through  the  opening  into  the  cavity  of  the 
skull,  in  order  to  break  up  the  brain  substance  in  all  directions. 
It  should  especially  be  passed  down  to  the  foramen  magnum,  to 
destroy  the  medulla  oblongata.  The  use  of  any  force,  such  as 
might  risk  the  point  of  the  perforator  being  passed  through  the 
skull  on  the  opposite  side,  must  of  course  be  avoided.  The  object 
of  destroying  the  medulla  is  to  make  certain  that  the  child  will  not 
cry  or  breathe  after  being  delivered  with  a  crushed  head,  and  so 
distress  the  mother  or  friends.  It  is  apt  to  cry  if  delivered  quickly, 
notwithstanding  the  destruction  of  the  main  part  of  the  brain, 
provided  that  the  medulla  oblongata  is  intact.  Hence  it  is  well,  for 
the  same  reason,  to  wait  a  few  minutes  after  breaking  up  the  brain 
before  beginning  the  extraction. 

It  is  recommended  by  some  to  pass  a  tube  into  the  cranial  cavity 


888 


The  Practice  of   Midwifery. 


and  wash  out  the  brain  substance  with  a  stream  of  water.  This 
is  not  essential  in  easy  cases,  but  should  be  done  whenever  much 
difficulty  is  anticipated ;  for  the  whole  of  the  brain  substance 
is  not  evacuated  either  by  the  pressure  of  the  pelvic  walls  in 
extraction,  or  by  that  of  crushing  instruments.  That  brain  sub- 
stance which  remains  resists  the  collapse  of  the  head,  or  bulges  it 

out  at  each  side  of  the  tract  compressed 
between  the  blades  of  the  cephalotribe. 

Methods  of  Extraction. 

After  perforation  of  the  head  the 
child  may  be  extracted  in  one  of 
several  ways.  In  an  easy  case,  with 
little  or  no  contraction  of  the  pelvis, 
it  is  often  sufficient  to  make  traction 
upon  the  head  with  a  pair  of  modified 
craniotomy  forceps,  the  so-called 
cranio-tractor  (see  Fig.  443). 

In  cases  of  greater  disproportion  or 
higher  degrees  of  pelvic  contraction, 
it  may  be  necessary  to  crush  the  head 
before  extracting  it  with  one  or  other 
of  the  forms  of  cephalotribe. 

In  a  third  class  of  case,  where  very 

marked   contraction   of    the   pelvis   is 

present,  and  it  is  necessary  to  deliver 

the  mutilated  child  through  the  natural 

passages,  it  is  best,  not  only  to  crush 

the  head,  but  to  further  diminish  its 

size  by  removing  the  vault  of  the  skull 

(the  so-called  operation  of  cranioclasm),  and  then  to  induce  a  face 

presentation,  and  if  necessary  to  crush  the  remainder  of  the  skull 

before  extraction. 


Fig.  4-1:1. — Craniotomy  forceps 
with  a  screw  to  handles. 


Craniotomy  Forceps. — Craniotomy  forceps  may  be  used  in  two 
totally  different  operations,  which  should  be  carefully  distinguished 
from  each  other.  In  the  one,  the  instrument  is  used  simply  as 
a  tractor,  the  diminution  in  the  size  of  the  head  being  effected  by 
the  pressure  of  the  pelvis.  In  the  other,  it  is  used  to  break  off 
and  tear  away  pieces  of  the  vault  of  the  skull,  and  so  reduce  the 
size  of  the  head,  the  operation  of  cranioclasm.  That  form  of 
craniotomy  forceps  which  has  a  screw  to  approximate  the  handles 


Craniotomy  and   Embryotomy. 


889 


may  be  put  to  yet  a  third  use  under  exceptional  circumstances,  as 
when  a  face  presentation  is  induced  after  cranioclasm,  namely,  to 
crush  the  remnant  of  the  head. 

Varieties  of  the  Tnstiument. — The  simplest  form  of  craniotomy 
forceps  is  that  in  which  the  blades 
are  hinged,  as  in  Fig.  441.  This 
may  be  used  as  a  tractor,  the 
smaller  blade  being  passed  into 
the  skull  through  the  opening 
made  by  the  perforator,  the  larger 
one  outside  the  scalp,  so  that  the 
curvature  of  the  blades  corre- 
sponds to  the  curvature  of  the 
head.  It  may  also  be  used  to 
break  away  pieces  of  the  skull  in 
cranioclasm.  The  fenestra  in  the 
larger  blade  allows  a  firmer  hold 
of  the  head  to  be  taken  when  the 
instrument  is  used  as  a  tractor. 

Sir  James  Simpson  made  the 
blades  separable,  and  united  by  a 
lock  similar  to  the  French  forceps 
lock.  The  instrument  so  produced 
he  called  a  cranioclast,  though  it  is 
more  adapted  for  use  as  a  tractor 
than  as  a  crusher.  Two  modifica- 
tions of  this  instrument  are  almost 
identical  with  each  other.  One  is 
Braun's  cranioclast  much  used 
in  Germany;  the  other  Barnes' 
craniotomy  forceps.  Both  these 
are  adapted  chiefly  for  use  as 
tractors,  and  in  both  the  handles 
are  approximated  by  a  screw. 
This  is  a  great  improvement, 
since  it  enables  a  very  firm  hold  to 
be  maintained  without  fatigue  to  the  hand,  and  also  allows  the 
instrument  to  be  used  for  crushing,  if  desired.  There  is  still 
further  improvement  in  Roper's  craniotomy  forceps  (Fig.  442). 
The  lock  in  these  is  the  English  lock,  and  is  therefore  easier  to 
adjust,  and  it  is  nearer  to  the  handles.  It  is  thus  always  outside 
the  vulva,  and  can  be  adjusted  without  any  risk  of  nipping  the 
mucous  membrane.      The  instrument  is  so  made  that  the  same 


Fig.  442. — Koper's  craniotomy  forceps. 


890 


The   Practice  of   Midwifery. 


screw  can  be  used  for  it  as  for  Hicks'  cephalotribe.  It  would  be 
preferable  to  have  the  screw  attached  by  a  hinge  to  the  handle  of 
the  solid  blade. 

Cases  suitable  for  Extraction  by  C raniotomy  Forceps. — There  has 

been  much  controversy  as  to  the 
relative  merits  of  extraction  by 
cephalotribe  or  craniotomy  forceps 
(the  so-called  cranioclast).  On  the 
Continent,  where  the  cephalotribes 
chiefly  in  use  are  very  large  and 
formidable  instruments,  the  cranio- 
tomy forceps  have  found  favour 
with  many,  being  considered  to 
involve  less  risk  of  injury  ;  but  a 
cei^halotribe  such  as  that  of  Hicks 
will  be  found  safer  as  well  as  easier 
to  use  in  all  ordinary  cases ;  for 
since  the  craniotomy  forceps  grasp 
only  the  vault  of  the  skull,  and  not 
the  whole  head  so  completely  as 
the  cephalotribe  (see  Fig.  445), 
they  are  more  likely  to  tear  away 
the  bone,  when  there  is  much 
resistance,  and  so  cause  dangerous 
angles  to  project. 

The  cases  specially  suitable  for 
the  use  of  craniotomy  forceps  are 
those  in  which  the  space  is  con- 
tracted in  all  its  dimensions,  so  that 
the  head  flattened  out  in  one  direc- 
tion in  the  grasp  of  the  cephalotribe 
cannot  find  any  diameter  large 
enough  to  admit  its  greatest  dia- 
meter. This  may  occur  in  the 
pelvis  sequabiliter  justo  minor,  and 
also  when  the  w4iole  circuit  of  the 
cervix  is  involved  in  cancer.  The 
mechanism  by  which  the  use  of  craniotomy  forceps  is  then  specially 
advantageous  is  the  following  : — The  head  is  elongated  in  the 
direction  of  the  pelvic  axis  by  the  traction,  and  at  the  same  time 
is  crushed  in  all  other  directions  by  the  pressure  of  the  pelvic 
wall  or  cervix,  so  that  all  its  other  diameters  are  reduced  in 
almost  equal   proportions.       This   is   illustrated   in   Fig.    443,   in 


Fig.  443. — Elongation  of  head  in 
conical  form  by  extraction  with 
craniotomy  forceps  (cranio- 
tractor). 


Craniotomy  and   Embryotomy.  891 

which  the  dotted  line  indicates  the  original  outline  of  the  head. 
If,  however,  the  cephalotribe  is  applied  in  the  most  favourable 
possible  way,  so  as  to  tilt  the  base  of  the  skull  into  a  position 
of  flexion  as  in  Fig.  445,  p.  894,  it  is  not  found  practically 
that  the  diameter  at  right  angles  to  the  compressed  one  is 
enlarged  by  the  pressure  ;  and  in  such  case  the  cephalotribe  is  equal 
or  superior  to  the  craniotomy  forceps,  even  for  extraction  through 
a  uniformly  contracted  opening  ;  the  maximum  diameter  in  either 
case  being  the  transverse  diameter  of  the  base.  In  the  absence  of 
the  cephalotribe,  craniotomy  forceps  are  the  best  instrument  for 
extraction  in  other  cases  also. 

Mode  of  using  Craniotomy  Forceps  as  a  Tractor. --^\iQ  left  hand 
is  passed  into  the  vagina,  and  the  fingers  placed  upon  the  aperture 
in  the  skull.  The  solid  blade  of  the  craniotomy  forceps  is  taken 
first,  and  guided  by  the  fingers  of  the  left  hand  into  the  aperture, 
so  that  it  passes  into  the  interior  of  the  skull,  underneath  the 
bones.  The  object  should  be  to  seize,  not  merely  the  parietal,  but 
the  occipital  or  frontal  bone,  since  the  parietal  bone  more  easily 
tears  away  from  the  base  of  the  skull.  The  serrated  surface  of  the 
blade  should  therefore  be  directed  toward  the  side  of  the  pelvis 
where  the  occiput  or  forehead  lies,  and  the  blade  should  be  pushed 
into  the  skull  as  far  as  it  will  go,  so  that  as  much  as  possible 
of  the  bone  may  be  secured.  Of  the  two  bones  the  occipital  is 
preferable,  because  traction  then  promotes  flexion  of  the  head  ;  but, 
if  the  occiput  is  directed  forward,  the  frontal  bone  is  easier  to 
seize,  because  the  outside  blade  is  more  easily  passed  up  at  the 
posterior  part  of  the  pelvis.  The  fenestrated  or  external  blade 
is  next  taken,  and  passed  up  outside  the  scalp,  in  such  a  direction 
as  to  correspond  to  the  other  blade.  The  depth  to  which  it 
should  be  passed  must  be  regulated  by  the  position  of  the  other 
blade,  so  that  the  lock  may  be  adjusted.  The  instrument  is  then 
screwed  up  as  tightly  as  possible,  and  traction  made  in  the  pelvic 
axis.  Frequent  examinations  must  be  made,  to  see  whether 
the  instrument  is  slipping,  or  any  angles  of  bone  beginning  to 
project.  Such  projecting  angles  must  be  nipped  off.  If  the  force  of 
traction  which  can  be  exerted  by  one  hand  is  found  sufiicient,  it  is 
well  to  keep  the  left  hand  constantly  in  the  vagina,  to  watch  the 
progress.  If  the  instrument  slips,  or  the  main  portion  of  the 
bone  which  it  is  holding  tears  away,  it  must  be  unscrewed  and 
reapplied,  if  possible  in  such  a  way  that  its  grasp  extends  more 
deeply.  If  the  pelvis  is  flattened  and  the  occipital  bone  has  been 
seized  so  as  to  secure  extreme  flexion  of  the  head,  it  is  sometimes 
advantageous,    if  the   head   does   not   easily  pass,    to    rotate   the 


892 


The   Practice  of   Midwifery. 


instrument  so  as  to  bring  the  transverse  diameter  of  the  head  into 
the  transverse  of  the  pelvis.  Unless  this  is  done  the  width  of 
the  base  of  the  skull,  about  3  inches,  is  the  limit  to  the  size 
of  conjugate  through  which  the  head  can  be  brought.  But  the 
antero-posterior  diameter  of  the   extremely   flexed    skull  may  be 

reduced  by  pressure  of  the 
pelvic  wall  somewhat  below 
this. 

The  Cephalotribe. — The 

cephalotribe  is  designed  to 
act  both  as  a  crusher  and 
extractor  of  the  head.  The 
requirements  of  a  good 
instrument  are — first,  that 
it  should  be  sufficiently 
strong  not  to  yield  in  the 
slightest  degree  under  tbe 
powerful  force  exerted  by 
the  screw  which  approxi- 
mates the  handles ;  secondly, 
the  width  across  the  blades 
should  be  as  little  as  possible 
when  they  are  closed,  that 
the  instrument  may  be 
capable  of  dragging  the 
head  through  a  greatly 
flattened  pelvis;  thirdly,  the 
blades  should  be  able  to  hold 
the  crushed  head  without 
slipping ;  for  this  purpose 
the  blades  are  generally 
made  with  somewhat 
incurved  ends,  and  with  transverse  serrations  on  the  inside. 
Fourthly,  the  instrument  should  be  so  shaped  that  it  can  be  applied 
with  ease.  For  this  purpose,  it  must  be  as  long  as  the  long  curved 
forceps,  that  it  may  be  able  to  seize  the  head  when  arrested  quite 
above  the  brim,  and  it  should  have  some  degree  of  pelvic  curve, 
like  that  of  the  long  curved  forceps.  It  is  better,  however,  to 
have  the  pelvic  curve  made  somewhat  slighter  than  that  usual 
with  long  curved  forceps.  The  instrument  can  then  more  easily 
be  rotated  through  a  quarter  of  a  circle,  in  order  to  bring  the 
flattened    head    through   the    brim   of   a   flattened    pelvis.      The 


'BBKiiSriiifiiimnilinMTO^^^ 


Fig.  44-i. — Braxton  Hiclvs'  cephalotribe. 


Craniotomy  and   Embryotomy.  893 

instrument  then  becomes  virtually  straight,  as  regards  its  relation 
to  the  curve  of  the  genital  canal.  If  it  had  a  strong  pelvic  curve, 
the  ends  of  the  blades  would  be  liable  to  injure  the  lateral  wall  of 
the  pelvis. 

A  form  of  cephalotribe  much  used  is  that  of  Dr.  Braxton  Hicks 
(Fig.  444).  The  blades  are  nearly  parallel  when  the  instrument  is 
closed,  but  incurved  at  the  ends.  The  pelvic  curve  is  not  greater 
than  about  20°  in  all,  so  that,  when  the  instrument  is  laid  flat  upon 
a  table,  convex  side  downward,  the  ends  of  the  blades  are  not 
separated  from  the  table  by  more  than  about  an  inch.  When  the 
instrument  is  closed,  the  width  across  the  blades  is  not  greater  than 
If  inches.  The  form  of  screw  shown  in  Fig.  443,  p.  890,  is  more 
convenient  for  the  fingers  than  the  original  pattern,  as  shown  in 
Fig.  444.  It  would  be  still  more  convenient  to  have  the  screw 
attached  by  a  hinge  to  the  lower  blade.  The  lock  is  of  the  English 
form,  and  therefore  more  easy  to  adjust  than  that  of  foreign 
instruments. 

Auvard's  three-bladed  instrument  presents  some  advantages  over 
that  of  Braxton  Hicks,  and  is  perhaps  rather  easier  to  apply,  and 
when  properly  applied  less  likely  to  slip  (Fig.  447). 

Cases  suitable  for  the  Cephalotribe. — In  all  ordinary  cases  of 
craniotomy,  extraction  can  be  effected  by  the  cephalotribe  more  easily 
and  rapidly  than  by  any  other  means,  and  with  less  chance  of  any 
angles  of  bone  projecting  and  injuring  the  soft  parts.  It  is  there- 
fore an  instrument  which  all  practitioners  will  find  it  worth  while 
to  possess.  When,  however,  the  child  has  to  pass  through  an 
aperture  narrowed  in  all  directions,  as  in  the  case  of  the  pelvis 
sequabiliter  justo  minor,  or  a  cervix  contracted  by  cancer  or  by 
cicatrices,  the  head,  flattened  in  the  grasp  of  the  cephalotribe,  has 
an  unsuitable  shape  for  passing  when  the  contraction  is  great. 
Since  the  breadth  across  the  blades  when  the  instrument  is  closed 
is  only  If  inches,  the  head  may,  under  the  most  favourable  circum- 
stances, be  brought  by  the  cephalotribe  through  a  space  measuring 
only  1^  inches  in  its  smallest  diameier,  provided  that  the  trans- 
verse diameter  bisecting  this  smallest  diameter  measures  as  much 
as  somewhat  over  3  inches.  It  follows  that  extraction  may  some- 
times be  effected  by  the  cephalotribe  in  quite  as  high  a  degree  of 
contraction  in  flattened  pelves  as  by  any  other  possible  means. 
For  this  result,  however,  it  is  essential  that,  while  the  blades  grasp 
the  head  pretty  centrally,  the  extremities  of  the  blades  should  be 
free  on  the  other  side  of  the  head,  and  capable  of  meeting,  as  in 
Fig.  445,  p.  894.  If  the  neck,  or  thorax,  or  part  of  the  head 
intervenes  Ijetween  the  ends  of  the  blades,  the  instrument  cannot 


894 


The   Practice  of   Midwifery. 


be  closed  so  completely,   and  will  not  pass  through  so  small  a 
space. 

It  is  frequently  a  difficult  matter  to  succeed  in  applying  the 
cephalotribe  centrally  over  the  head,  in  such  a  way  that  the  instru- 
ment can  be  completely  closed.  Hence,  in  extreme  forms  of  pelvic 
contraction,  other  modes  of  extraction  shortly  to  be  described  come 

into  competition  with  the  use  of  the 
cephalotribe,  and  may  sometimes 
succeed  when  the  cephalotribe  has 
failed. 

The  diminished  pelvic  inclination 
usually  found  in  the  flattened  rachitic 
pelvis  facilitates  the  use  of  the  cepha- 
lotribe ;  an  increased  pelvic  inclination 
renders  it  more  difficult,  when  con- 
traction is  extreme,  especially  as  com- 
pared with  the  method  of  induction  of 
face  presentation  after  cranioclasm  (see 
p.  899). 

Method  of  operating. — The  blades  are 
to  be  passed  at  the  sides  of  the  pelvis, 
without  4.'egard  to  the  position  of  the 
head.  Generally  the  head  is  caught 
somewhat  diagonally,  as  by  the  blades 
of  forceps ;  but  if  the  head  is  above 
the  brim  in  a  flattened  pelvis,  it  is  very 
likely  to  be  caught  by  the  two  blades 
over  forehead  and  occiput,  as  shown 
in  Fig.  445,  and  this  is  the  most 
favourable  way  of  seizing  it.  As  with 
the  ordinary  forceps,  the  lower  blade 
is  to  be  passed  first.  The  fingers  of 
the  left  hand  are  passed  into  the  vagina 
and  within  the  cervix,  and  the  blade 
guided  up  just  like  the  blade  of  forceps.  The  second  or  upper  blade 
may,  like  the  upper  blade  of  forceps,  be  at  first  passed  up  opposite 
the  sacro-iliac  articulation,  the  handle  being  carried  forward 
between  the  thighs,  and  the  blade  afterwards  swept  round  to  the 
right  of  the  pelvis  by  carrying  the  handle  downward  and  backward. 
The  blade  does  not,  however,  glide  laterally  over  the  head  so  easily 
as  that  of  forceps,  on  account  of  the  serrations  on  its  inner  margin, 
and  its  incurved  extremity.  Hence,  if  it  is  found  difficult,  by  this 
mode  of  introduction,  to  get  the  blade  exactly  opposite  to  the  lower 


Fig.  445. — Head  crushed  by 
cephalotribe. 


Craniotomy  and   Embryotomy.  895 

one,  it  is  better  to  pass  it  at  once  up  the  side  of  the  pelvis,  having 
the  patient  quite  at  the  edge  of  the  bed,  and  depressing  the  handle 
strongly.  Both  blades  should  be  passed  on  until  the  whole  of  the 
serrated  portion  of  their  inner  surface  is  out  of  reach,  lying  against 
the  head  (see  Fig.  445). 

In  order  to  adjust  the  lock,  the  handles  should  be  pressed  back 
against  the  perineum,  somewhat  more  than  those  of  forceps,  so 
that  the  blades,  with  their  pelvic  curve  slighter  than  that  of  forceps, 
may  seize  the  head  centrally.  Tbe  screw  is  then  api^lied,  and 
before  it  is  tightened  the  left  band  makes  sure  that  the  blades  are 
at  opposite  sides  of  the  head.  If  they  are  too  near  together,  either 
at  the  back  or  the  front  of  the  pelvis,  they  will  slip  either  backward 
or  forward  off  the  convexity  of  the  head  as  the  screw  is  tightened. 
The  instrument  is  then  screwed  up  as  tightly  as  possible.  The 
operator  should  first  have  noticed  how  nearly  the  handles  approxi- 
mate when  the  instrument  is  completely  closed,  and  should  endeavour 
to  screw  them  up  as  nearly  as  possible  to  this  position  ;  for  if  the 
inner  surfaces  of  the  blades  are  divergent  instead  of  parallel  or 
nearly  so,  the  instrument  is  liable  to  slip  off  when  traction  is  made. 
As  the  screw  is  tightened,  the  brain  substance  will  be  squeezed  out, 
if  it  has  not  previously  been  washed  out  with  a  stream  of  water. 
When  the  crushing  is  completed,  the  left  hand  should  be  passed  up 
again  to  feel  whether  the  blades  have  slipped  off,  or  are  grasping 
the  head  centrally.  There  will  now  be  room  to  pass  the  hand 
further  into  the  uterus,  to  make  out  their  exact  position.  The 
operator  should  also  make  sure  that  there  are  no  projecting  angles 
of  bone  at  the  point  of  perforation.  If  any  are  found  the  pieces  of 
bone  should  be  pulled  away  with  the  fingers  or  small  craniotomy 
forceps  (see  Fig.  441,  p.  888),  or  the  angles  should  be  nipped  off 
with  a  pair  of  bone-nipping  forceps,  which  are  a  useful  adjunct  to 
the  obstetric  bag.  Generally  it  will  be  found  that,  if  the  head  is 
properly  grasped,  the  angles  of  bone  are  covered  by  the  scalp, 
as  shown  in  Fig.  445,  or  are  shielded  between  the  shanks  of  the 
instrument. 

If  it  is  found  that  the  blades  have  slipped  more  or  less  off  the 
head,  backward  or  forward,  the  screw  should  be  loosened,  and  the 
blades  reapplied  more  centrally.  There  will  now  be  probably  room 
to  i)ass  the  hand  up  into  the  uterus  by  the  side  of  the  head,  in  order 
to  adjust  the  position  of  the  blades.  The  crushing  is  then  repeated. 
In  a  difficult  case  it  may  be  necessary  to  repeat  this  process  several 
times  in  succession,  l>efore  a  sufficiently  central  grasp  is  secured. 
It  is  more  dangerous  to  make  traction  when  the  blades  are  rather 
in  front  of  the  centre  of  the  head  (in  reference  to  the  pelvis)  than 


896 


The   Practice  of   Midwifery. 


when  they  are  rather  behmd  it  as  m  Fig.  445 ;  for,  in  the  former 
case  the  tips  of  the  blades  are  hable  to  project  and  injure  the  soft 
parts. 

Supposing  that  a  sufficiently  central  grasp  has  been  secured, 
traction  is  to  be  commenced.     If  the  head  is  already  in  the  cavity 


m 


Fig.  446. — Simpson's 
splitting  basilyst. 


Fig.  447. — Auvard's  three-bladed  cephalotribe. 


of  the  pelvis,  or  if  the  pelvis  is  uniformly  contracted,  the  cephalo- 
tribe is  to  be  drawn  down  in  the  position  in  which  it  was  applied. 
If,  however,  the  pelvis  is  flattened,  and  the  head  is  still  above  the 
brim,  the  cephalotribe  should  be  rotated  through  nearly  a  quarter 
of  a  circle.  This  will  bring  the  long  diameter  of  the  flattened  head 
to  correspond  with  the  transverse  diameter  of  the  flattened  brim, 
whereas  at  first  the  head  was  flattened  out  in  the  direction  of  the 
contracted  conjugate.  In  extreme  degrees  of  contraction  of  the  con- 
jugate, care  should  be  taken  that  the  instrument  is  so  far  screwed 


Craniotomy  and   Embryotonn.y.  897 

up  as  to  close  it  completely,  or  almost  completely,  before  traction 
is  begun  ;  for  it  would  be  dangerous  to  make  pressure  upon  the 
symphysis  pubis  and  promontory  of  the  sacrum  by  the  diverging 
blades  of  the  instrument  itself.  Traction  must  be  made  in  a 
direction  as  much  backward  as  possible,  until  the  head  has  passed 
the  brim.  It  will  probably  not  be  possible  to  pull  accurately  in  the 
axis  of  the  brim,  since  the  advantage  of  the  pelvic  curve  of  the 
cephalotribe  is  now  almost  or  entirely  lost,  its  concavity  being 
turned  to  one  side.  If  the  cervix  is  not  at  first  fully  expanded, 
ample  time  must  be  allowed  for  it  to  dilate.  The  hand  should  also 
be  introduced  from  time  to  time  to  ascertain  if  the  blades  keep  in 
position,  and  whether  any  angles  of  bone  begin  to  project.  Any 
such  angles  should  be  nipped  off  as  before.  As  the  head  descends 
to  the  pelvic  floor,  traction  is  to  be  made  more  forward,  and  the 
cephalotribe  may  be  allowed  to  rotate  in  any  direction  to  which  the 
resistances  impel  it.  Generally  it  will  be  found  that  the  shanks 
tend  to  rotate  forward  under  the  pubic  arch,  like  the  leading  portion 
of  the  presenting  part  of  the  foetus,  and  thus  the  cephalotribe  passes 
the  pelvic  outlet  with  its  concavity  directed  backward.  It  has  thus 
been  rotated  through  half  a  circle  in  all.  It  will  most  commonly 
be  found  that  the  hard  base  of  the  skull  has  not  been  broken  up  by 
the  cephalotribe,  but  tilted  in  the  grasp  of  the  blades,  either  laterally 
or  longitudinally.  It  is  best  for  the  base  of  the  skull  to  be  tilted 
into  a  position  of  flexion,  as  shown  in  Fig.  445,  because  then  the 
maximum  diameter  of  the  flattened  head  does  not  much  exceed  the 
transverse  diameter  of  the  base  of  the  skull,  or  about  3  inches. 

In  general  the  tilting  of  the  base  of  the  skull  is  quite  sufficient, 
and  there  is  no  necessity  for  breaking  it  up.  Such  breaking  up 
could  only  be  useful  when  transverse  diameter  as  well  as  conjugate 
is  much  contracted.  An  instrument  for  the  purpose,  the  basilyst, 
has  been  introduced  by  Prof.  A.  E.  Simpson,  of  Edinburgh.  It 
is  first  screwed  into  the  base  of  the  skull,  and  the  blades  then 
separated.     The  cephalotribe  may  be  applied  afterwards. 

The  introduction  of  the  three-bladed  cephalotribe  is  carried  out 
as  follows : — The  middle  blade  is  first  introduced  as  far  as  possible 
into  the  skull  through  the  opening  made  by  the  perforator.  This 
blade  having  been  placed  in  position,  one  of  the  external  blades  is 
next  introduced  either  over  the  frontal  or  occipital  region  of  the 
head.  It  is  passed  in  under  cover  of  the  fingers  of  the  left  hand  at 
the  side  of  the  pelvis  and  rotated  into  position  over  the  external 
surface  of  the  head.  The  screw  is  now  turned,  and  the  part  of  the 
head  which  has  been  seized  crushed.  As  in  the  employment  of 
Braxton  Hicks'  cephalotribe,  the  ease  or  difficulty  with  which  the 
M.  57 


898 


The  Practice  of   Midwifery. 


crushing  can  be  carried  out  is  a  good  index  of  the  manner  in  which 
the  head  has  been  seized.  If  there  is  a  good  deal  of  resistance  to 
the  crushing,  almost  certainly  a  good  grasp  of  the  head  has  been 
secured.  One  portion  of  head  having  been  crushed  in  this  way,  the 
other  blade  is  now  introduced  at  the  opposite  side  of  the  pelvis  in 
the  same  manner,  the  screw  fixed,  and  the  head  again  crushed.  In 
extracting  the  crushed  head  the  instrument  should  be  allowed  to 
rotate  spontaneously,  or  if  it  shows  no  signs  of  doing  this,  then  it 
should  be  rotated  so  that  the  crushed  diameter 
may  occupy  the  smallest  diameter  of  the  pelvis. 

Cranioclasm. — The  operation  of  cranioclasm 
is  much  more  difficult  and  tedious  than  extraction 
by  the  cephalotribe  or  craniotomy  forceps.  It 
also  involves  risk  of  injury  both  to  the  soft  parts 
and  to  the  operator's  fingers  by  the  angles  of 
detached  bone.  It  should  only  be  undertaken, 
therefore,  in  those  cases  of  extreme  difiiculty  in 
which  the  operator  cannot  efl:ect  extraction  by 
one  of  the  two  former  methods  without  exerting 
a  dangerous  degree  of  force. 

Method  of  operating.— The  best  instrument 
for  removal  of  pieces  of  bone  is  a  pair  of  cranio- 
tomy forceps,  such  as  those  shown  in  Fig.  448, 
or,  still  better,  one  in  which  both  blades 
are  solid  without  fenestra.  The  instrument  is 
passed  up  to  the  head  under  the  guidance  of  the 
left  hand  in  the  vagina.  One  blade  is  passed 
between  the  cranial  bones  and  the  scalp,  the 
other  through  the  aperture  into  the  interior  of 
the  skull.  If  possible  the  instrument  should  be  so 
passed  that  its  curve  corresponds  to  that  of  the 
head,  for  then  it  is  likely  to  secure  a  larger  piece  of  bone ;  but  if 
it  is  found  easier  to  turn  it  the  reverse  way,  and  pass  the  other 
blade  between  the  bone  and  the  scalp,  there  is  no  objection  to 
doing  so.  The  bone  is  then  grasped,  and  a  sudden  twist,  first  in 
one  direction,  then  in  the  other,  is  given  to  the  instrument  so  as 
to  break  the  piece  of  bone  in  its  grasp  away  from  surrounding 
parts.  The  forceps  are  then  twisted  round  and  round  till  the 
piece  of  bone  is  entirely  detached,  and  finally  the  piece  is  drawn 
out,  covered  by  the  left  hand,  and  so  prevented  from  lacerating 
the  soft  parts.  The  piece  of  bone  should  be  in  the  palm  of  the 
hand,  the  fingers  closed  over  it,  so  that  it  is  brought  down  ivithin  the 


Fig.  448.— 
Craniotomy  forceps, 


Craniotomy  and   Embryotomy.  899 

closed  fist,  and  cannot  possibly  touch  any  soft  parts.  This  process 
is  to  be  continued  until  nearly  the  whole  of  the  vault  of  the  skull 
has  been  removed,  including  the  whole  of  the  parietal  bones.  The 
student  must  take  care  to  remember  that  in  cranioclasm  the  outer 
blade  is  passed  between  the  scalj)  and  the  bone,  but  that,  when 
craniotomy  forceps  are  used  as  a  tractor,  it  is  passed  outside  the 
scalp. 

Induction  of  Face  Presentation. — When  the  vault  of  the  skull  has 
been  broken  up  and  in  great  part  removed,  the  best  way  to  deliver 
the  head  in  a  greatly  contracted  pelvis,  especially  one  with  a  very 
small  conjugate  diameter,  is  to  induce  a  face  presentation.  If  the 
chin  be  brought  to  the  front,  the  diameter  opposed  to  the  conjugate 
is  then  only  the  vertical  diameter  of  the  face,  little  more  than  1  inch, 
and  that  opposed  to  the  transverse  is  the  bi-mastoid  or  bi-zygomatic 
diameter,  not  more  than  3  inches.  The  face  may  be  brought  to 
present  by  the  small  blunt  hook  already  described  as  useful  for 
securing  the  knee  in  version  (see  p.  881).  The  hook  is  fixed  first 
into  the  orbit,  and  then,  after  the  orbit  has  been  brought  down, 
upon  the  chin,  or  some  part  of  the  lower  jaw  near  it.  The  chin 
having  been  completely  drawn  down,  so  that  the  face  presents, 
delivery  may  be  completed  in  one  of  two  ways.  The  blunt  hook 
may  be  transferred  to  the  inner  surface  of  the  base  of  the  skull,  be 
fixed  into  some  of  the  projections  of  bone  there,  and  so  draw  the 
head  down ;  or  the  craniotomy  forceps  with  a  screw  at  the  handle 
(Fig.  442,  p.  889)  may  be  used.  This  is  the  only  condition  in 
which  this  instrument  can  be  used  with  advantage  as  a  crusher  as 
well  as  a  tractor.  The  solid  blade  is  passed  in  front  of  the  chin, 
the  fenestrated  blade  over  the  base  of  the  skull,  and  the  screw 
tightened  as  much  as  possible.  Thus  the  small  vertical  diameter 
of  the  head  which  remains  is  still  further  compressed.  This 
method  of  delivery  is  most  useful  when  the  vault  of  the  skull  has 
not  been  completely  removed.  In  the  absence  of  the  small  blunt 
hook,  the  crochet  (Fig.  449)  may  be  used  in  its  place  in  this 
operation.  This  method  of  delivery  is  the  best  adapted  of  any  to 
overcome  extreme  conditions  of  contraction  affecting  transverse  as 
well  as  conjugate  diameter ;  for  the  base  of  the  skull  is  brought 
down  in  its  most  favourable  position,  which  it  will  not  always  be 
when  tilted  in  the  grasp  of  the  cephalotribe. 

Version. — Version  is  sometimes  performed  to  facilitate  delivery 
after  craniotomy.  In  the  extraction  of  the  after-coming  head,  the 
skull  collapses  under  the  pressure  of  the  pelvis,  and  the  bones 
generally  remain  covered  by  the  scalp.     Version  may  be  performed 

57—2 


900 


The  Practice  of   Midwifery. 


with  advantage  in  the  absence  of  an  efficient  cephalotribe  or  cranio- 
tomy forceps,  or  if  the  operator  does  not  succeed  with  either  of 
these  instruments,  when  the  degree  of  contraction  is  not  very 
extreme,  especially  if  it  is  found  that  angles  of  bone  protrude. 
The  cephalotribe  may  be  applied  again  to  the  after-coming  head, 
if  it  will  not  otherwise  readily  pass  the  brim,  after  liberation  of 
the  arms.  In  very  extreme  contraction,  the  extraction  of  the  body 
might  cause  difficulty,  owing  to  the  extension  of  the  arms.     In  such 

cases  it  is  preferable  to  perform  cranioclasm,  and  then 

induce  a  face  i3resentation. 


Secondary  Symphysiotomy.  —  When  it  proves 
impossible  to  extract  after  craniotomy  without  a 
dangerous  amount  of  traction,  symphysiotomy  or 
pubiotomy  has  been  suggested  as  a  means  of  gaining 
more  room  in  the  pelvis.  The  same  operation  may  be 
chosen  in  preference  to  the  prolonged  and  difficult 
operation  of  cranioclasm.  These  operations  have, 
however,  a  less  favourable  influence  on  the  pelvic 
diameters  in  extreme  contraction  of  the  conjugate  than 
they  have  when  general  contraction  forms  a  main  part 
of  the  difficulty,  and  would  very  seldom  be  justifiable 
in  these  conditions. 


Fig.  449.— 
Crochet. 


The  Crochet.  —  The  crochet  (Fig.  449)  was  the 
instrument  formerly  most  used  for  extraction  after 
craniotomy.  The  crochet  is  passed  through  the 
aperture  into  the  interior  of  the  skull,  and  fixed 
against  any  part  of  the  vault  of  the  skull  where  it  can 
obtain  a  firm  hold.^  The  fingers  of  the  left  hand  are 
j)laced  on  the  outside  of  the  scalp,  opposite  the  point  of 
the  crochet  and  pressing  against  it,  and  then  traction  is  made. 
The  disadvantage  of  this  jDroceeding  is  that  the  crochet  is  apt  to 
slip,  or  to  tear  away  the  piece  of  bone  which  it  is  holding,  and  so 
cause  laceration.  This  mode  of  extraction  should  not  therefore  be 
adopted  if  any  better  one  is  available.  The  crochet  is,  however, 
often  very  useful  in  the  extraction  of  a  dead  foetus,  when  fixed  into 
any  available  part  of  the  body,  in  order  to  secure  a  hold  for 
additional  traction.  Tbe  small  blunt  hook  may  be  used  in  the 
same  way. 

^  Studeots  often  say  at  an  examination  that  the  crochet  should  be  fixed  in  the 
foramen  inagnum.  This,  however,  is  impossible,  since  it  is  much  too  large.  The  only 
instrument  which  could  be  fixed  in  the  foramen  magnum  is  the  vertebral  hook 
invented  by  Dr.  Oldham  for  extraction  of  the  after-coming  head. 


Craniotomy  and   Embryotomy.  901 

Forceps. — Forceps  should  never  be  applied  to  deliver  the  head 
after  craniotomy,  because  they  are  liable  to  slip  off  as  the  head 
collapses.  Foreign  forceps  in  which  the  points  are  close  together 
when  the  handles  are  closed,  may  succeed  in  easy  cases,  but  the 
ordinary  English  forceps  are  of  little  use  for  this  jDurpose. 

Extraction  of  the  Body. — As  a  rule,  it  is  only  when  contraction 
is  extreme,  or  the  child  very  large,  that  extraction  of  the  body 
meets  with  much  difficulty.  The  cephalotribe  or  craniotomy  forceps 
should  be  kept  applied  to  the  head  to  furnish  a  good  hold  for  traction, 
until  the  thorax  has  passed  the  brim.  If  much  resistance  is  met 
with,  the  crochet  or  small  blunt  hook  may  be  fixed  in  one  axilla, 
so  as  to  draw  down  one  shoulder  in  advance  of  the  other.  If  this 
does  not  answer,  both  arms  may  be  drawn  in  front  of  the  chest 
by  the  same  means,  and  used  to  afford  an  additional  hold  for 
traction.  If  difficulty  is  still  experienced,  the  clavicles  should  be 
divided,  an  easy  method  of  reducing  the  width  of  the  child's 
shoulders.  The  operation  is  simple.  Under  cover  of  the  fingers  of 
the  left  hand,  the  clavicles  are  divided  with  a  pair  of  strong  straight 
scissors.-^ 

The  perforator  may  be  used  to  pierce  the  chest  and  abdomen,  but 
not  much  is  gained  by  this,  unless  the  abdomen  had  become  dis- 
tended by  decomposition.  If  necessary,  the  cephalotribe  may  be 
applied  over  the  chest,  and  afterwards  over  the  pelvis,  especially  if 
the  head  should  have  separated  and  come  away  from  the  trunk 
under  traction. 

Perforation  of  the  After-coming  Head. — In  the  case  of  the 
after-coming  head,  the  usual  method  of  craniotomy  has  been  to 
perforate  behind  the  ear  in  the  neighbourhood  of  the  postero- 
lateral fontanelle,  or  through  the  occipital  bone.  This  has  the 
disadvantage  that  the  point  of  the  perforator  impinges  on  the  skull 
at  a  very  acute  angle,  and  is  very  close  to  the  maternal  soft  parts. 
An  improved  method  has  been  introduced,  namely,  to  perforate 
through  the  roof  of  the  mouth.  The  blades  can  then  be  separated 
in  two  directions  at  right  angles,  as  in  the  case  of  the  fore-coming 
head.  If  the  head  has  become  at  all  extended,  care  must  be  taken 
to  direct  the  point  of  the  perforator  somewhat  backward  toward  the 
occiput,  otherwise  it  may  only  enter  the  orbit,  and  not  the  cavity 
of  the  skull.  In  one  respect  there  is  an  advantage  in  this  method 
even  over  perforation  of  the  fore-coming  head,  namely,  that  the 

1  Spencer,  Brit.  Med.  Journ.,  April  13,  1895,  p.  808  ;  Ballantyne,  Trans.  Obst.  ,Soc. 
Edin.,  Vol.  XXVI.,  p.  24. 


902  The   Practice  of   Midwifery. 

base  of  the  skull  is  more  or  less  broken  up.  For  this  reason 
Donald  has  advocated  preliminary  version  in  all  difficult  cases 
of  craniotomy  ;  ^    but  this  advice  has  not  been  generally  accepted. 

After  perforation  through  the  roof  of  the  mouth,  the  brain  sub- 
stance should  be  broken  up  with  the  perforator,  and  then  washed 
out  with  a  stream  of  water.  In  easy  cases  the  head  can  be 
extracted  by  traction.  In  difficult  ones  the  body  of  the  child 
should  be  held  forward  by  an  assistant,  while  the  blades  of  the 
cephalotribe  are  applied  at  the  sides  of  the  pelvis.  When  a  central 
hold  has  been  obtained  of  the  head,  the  instrument  should  be 
rotated  through  a  quarter  of  a  circle,  in  the  case  of  a  flattened 
pelvis,  and  so  drawn  down. 

Embryotomy  in  Pelvic  Presentations. — It  is  only  in  cases 
of  extreme  disproportion  that  the  body  of  the  child  cannot  be 
brought  through  the  brim  in  pelvic  presentations,  or  after  version. 
Sometimes,  however,  the  pelvis  of  the  child  refuses  to  enter  the 
pelvis  of  the  mother,  and  the  difficulty  is  then  greater  than  in  head 
presentations.  The  alternative  of  performing  Csesarean  section, 
eymphysiotomj^  or  pubiotomy,  before  much  effort  is  made  at  trac- 
tion, then  arises.  If  this  is  rejected,  both  legs  should  be  brought 
down,  and  traction  should  be  made  upon  them,  both  together  and 
separately,  in  order  to  find  out  the  best  way  of  bringing  down  the 
child's  pelvis.  If  the  child  is  dead  this  may  be  aided  by  the 
crochet  or  small  blunt  hook  fixed  over  the  pelvis.  If  the  abdomen 
of  the  child  has  become  distended,  after  death  of  the  fcetus,  it  may 
be  necessary  to  perforate  it. 

The  methods  of  performing  embryotomy  in  shoulder  presenta- 
tions, when  version  is  impossible,  have  already  been  described  (see 
p.  676). 

1  Trans.  Obst.  Soc.  London,  1889,  Vol.  XXXI.,  p.  28. 


Chapter   XXXVI, 

CESAREAN  SECTION,  SYMPHYSIOTOMY  AND 
PUBIOTOMY. 

C^SABEAN  Section. 

By  Caesarean  section  is  meant  the  removal  of  the  fcetiis  by 
incisions  through  the  walls  of  the  abdomen  and  the  uterus.  In 
the  variety  of  the  operation  introduced  by  Porro  it  is  completed 
by  the  excision  of  the  whole  of  the  body  of  the  uterus. 

History — Csesarean  section  is  a  mode  of  delivery  which  would 
naturally  suggest  itself  at  a  rude  period  of  surgical  art.  Tradition 
has  related  of  several  noted  men  of  ancient  days — such  as  iEscula- 
pius,  Scipio  Africanus,  Julius  Caesar — that  they  were  delivered  in 
this  way.  Although  the  tradition  is  not  believed  to  be  well  founded 
as  regards  Julius  Caesar,  the  derivation  of  the  title  "  Caesar  "  from 
"  A  matris  utero  ccesus  "  has  been  generally  accepted.  Such  tradi- 
tional accounts  are  open  to  the  interpretation  that,  if  true  at  all, 
they  refer  probably  in  most  cases  only  to  Caesarean  section  performed 
after  the  mother's  death.  But,  even  to  the  present  day,  Caesarean 
section  for  delivery  of  the  living  woman  is  practised  among  some 
savage  tribes  in  a  low  grade  of  civilisation,  as  in  the  interior  of 
Africa.^  This  affords  some  presumption  in  favour  of  the  view  that 
the  same  operation  may  have  been  performed  in  ancient  days. 
During  the  sixteenth  century  Caesarean  section  was  believed  to  have 
been  performed  in  various  instances,  during  the  life  of  the  mother, 
although  no  reliable  histories  of  the  cases  have  been  preserved. 
The  first  authentic  record  is  that  of  a  Caesarean  section  performed 
in  a  case  of  hernia  of  the  gravid  uterus  by  Trautman,  at  Wittenberg, 
in  1710.     The  patient  lived  twenty-five  days  after  the  operation. 

In  former  years  the  mortality  of  Caesarean  section  had  been  so 
high  as  to  restrict  the  operation  to  those  cases  in  which  delivery 
through  the  pelvis  was  either  impossible  or  so  difficult  as  to  involve 
very  great  risk  to  the  mother.  British  statistics  gave  a  mortality 
of  about  84  per  cent.      The  first  improvement  was  introduced  in 

1  "Notes  on  LaVjour  in  Central  Africa,"  by  R.  W.  Felkin,  Trans.  Obst.  See.  Edin. 
1884. 


904  The   Practice  of   Midwifery. 

1876,  by  Porro  of  Pavia,  who  followed  up  Cfesarean  section  by  the 
removal  of  the  whole  uterus  with  the  ovaries  in  a  case  of  pelvic 
contraction.  Thus  was  introduced  Porro's  operation,  hereafter  to 
be  described.  It  was  practised  in  a  good  many  cases  of  pelvic 
contraction  with  a  success  considerably  exceeding  that  of  the  old 
Cesarean  section.  The  modern  method  of  Caesarean  section  was 
first  suggested  by  Sanger  in  1882.  It  was  perfected  and  simplified 
chiefly  at  Dresden  and  Leipzig,  by  Leopold  and  other  operators, 
and  has  attained  such  success  as  to  displace  craniotomy  from  a 
considerable  portion  of  its  field.  Hitherto  the  operation  has  been 
performed  most  frequently  and  most  successfully  in  Germany, 
where  the  higher  degrees  of  pelvic  contraction  are  commoner  than 
in  England  or  America.  The  improvements  introduced  by  Sanger 
consist  essentially  in  the  adaptation  of  Lembert's  intestinal  suture 
for  the  superficial  sutures  of  the  uterine  peritoneum  ;  and  in  the 
use  of  a  large  number  of  sutures,  deep  and  superficial,  to  secure 
perfect  closure  of  the  uterine  wound,  so  that  the  lochial  discharge 
is  prevented  from  reaching  the  peritoneum. 

Indications  for  the  Operation. — The  indications  for  Caesarean 
section  have  already  been  described  in  the  chapters  dealing  with 
the  various  conditions  which  may  call  for  it.  They  are  chiefly 
comprised  in  the  following :  the  higher  degrees  of  pelvic  contrac- 
tion, and  some  cases  of  obstruction  of  the  pelvis  by  tumours, 
cancer  of  the  cervix,  inflammatory  deposits,  or  cicatrices  which 
cannot  be  stretched.  It  has  also  been  recommended  and  practised 
for  cases  of  accidental  hfemorrhage,  placenta  praevia,  and  eclampsia. 
In  Eoman  Catholic  countries  religious  scruples  about  destroying 
the  child  to  secure  the  safety  of  the  mother  have  influenced  the 
choice  between  craniotomy  and  Csesarean  section.  In  this  country 
the  interest  of  the  mother  will  still  be  held  paramount.  But  in 
cases  in  which,  owing  to  the  improvements  in  Caesarean  section,  the 
risks  of  the  two  operations  are  nearly  balanced,  the  interest  of  the 
child  is  justly  allowed  to  have  much  weight.  And  now  that  the 
risk  of  Caesarean  section  has  become  so  moderate,  it  is  reasonable,  if 
that  operation  can  be  performed  under  favourable  circumstances,  in 
any  case  in  which  the  child  is  likely  to  be  otherwise  sacrificed,  to 
offer  the  mother  the  option  of  undergoing  even  a  somewhat  greater 
risk,  to  save  the  life  of  her  child. 

Time  for  operating. — The  modern  success  in  Caesarean  section 
has  been  gained  chiefly  in  cases  in  which  the  operation  has  been 
decided   on   beforehand,    and  performed   at   the  most   favourable 


Csesarean   Section,   Symphysiotomy,    Etc.     905 

moment.  If  a  patient  has  long  been  in  labour,  extraction  through 
the  pelvis  is  safer,  except  in  the  more  extreme  forms  of  distortion, 
as,  for  instance,  when  the  conjugate  diameter  is  less  than  2f  inches. 
The  operation  may  be  undertaken  before  the  onset  of  labour,  or 
labour  may  be  allowed  to  commence  and  the  operation  performed 
when  partial  dilatation  of  the  cervical  canal  has  been  obtained. 
The  objection  that  if  the  operation  be  performed  before  the  dilata- 
tion of  the  cervix  there  is  a  difficulty  in  obtaining  sufficient  drainage 
through  the  cervical  canal  does  not  appear,  in  view  of  modern 
results,  to  be  of  much  importance.  If  it  is  thought  best,  labour  may 
be  induced  and  the  operation  commenced  as  soon  as  partial  dilata- 
tion of  the  cervix  has  been  secured.  For  this  purpose  a  dilator  may 
be  introduced  a  few  hours  before  the  time  fixed  for  the  operation. 
If,  however,  the  cervix  uteri  is  patent  enough  to  admit  the  index 
finger,  there  appears  to  be  no  objection  to  operating  without  any 
commencement  of  labour.  Experience  appears  to  show  that  failure 
of  the  uterus  to  retract  is  not  to  be  feared  when  labour  has  not  com- 
menced, but  only  when  the  uterus  is  fatigued  by  prolonged  labour. 

Preparation  of  the  Patient. — The  vagina  should  be  irrigated 
previously  with  lysol,  1  per  cent.  The  abdomen  should  be  carefully 
washed  with  soap  and  water,  the  umbilicus  cleaned  out  if  necessary 
by  liquor  potassse,  the  pubic  and  vulvar  hair  shaved.  If  time  allows, 
a  compress  soaked  in  perchloride  of  mercury,  1  in  1,000,  should  be 
kept  on  the  skin  for  some  hours  previous  to  the  operation.  The 
abdomen  should  then  be  washed  over,  first  with  lysol,  1  in  80, 
then  with  iodide  of  mercury  in  spirit,  1  in  500,  The  utmost  care 
should  be  taken  to  cleanse  all  instruments,  and  the  hands  of  all  who 
take  part  in  the  operation,  including  nurses,  from  any  possibility  of 
septic  contamination.  Hands  and  arms  are  best  disinfected  first  in 
lysol,  1  in  80,  and  finally  in  solution  of  iodide  of  mercury  in  spirit, 
1  in  500,  and  sterilised  rubber  gloves  should  always  be  worn.  The 
patient  may  be  placed  either  in  the  ordinary  dorsal  position,  or, 
if  it  be  preferred,  the  Trendelenburg  position  may  be  employed. 

Anaesthetic. — Ether  together  with  oxygen  rather  than  chloro- 
form should  be  chosen  for  the  anaesthetic,  since  it  does  not  relax  the 
uterus  so  completely.  If  the  uterus  fails  to  contract  well  after 
removal  of  the  foetus,  the  anaesthesia  should  not  be  maintained  too 
deeply.  It  must,  however,  be  sufficient  to  prevent  vomiting  or 
straining,  by  which  the  intestines  might  be  forced  out. 

Cesarean  section  has  often  been  performed,  especially  on  the 
Continent,  by  the  aid  of  local  analgesia  from  the  injections  of  a 


9o6  The   Practice  of   Midwifery. 

solution  of  cocain  or  eucain  at  the  site  of  incision.  A  general 
angesthetic  is  regarded  with  less  dread  in  this  country ;  but  the 
method  may  sometimes  be  advisable  if  the  operation  is  ever 
undertaken  when  the  uterus  is  very  inert  from  the  fatigue  of 
prolonged  labour ;  and  the  patient  is  endowed  with  self-restraint 
and  tolerance. 

The  Operation. — If  the  operation  is  arranged  for  beforehand, 
sterilised  gauze  rolls,  sterilised  artificial  sponges,  made  of  absorbent 
cotton  wrapped  in  gauze,  with  flat  j)ads  large  and  small,  should  be 
used,  or,  in  the  absence  of  these,  wads  of  cotton  wool,  sterilised  by 
boiling,  and  used  wet. 

The  field  of  operation  should  be  surrounded  with  towels  sterilised 
by  boiling,  and  wrung  out  of  lysol,  1  in  80.  The  bladder  should 
first  be  emptied.  Then  an  incision  is  made  in  the  linea  alba.  This 
should  be  about  six  inches  long,  and  from  a  third  to  half  of  it 
should  be  above  the  level  of  the  umbilicus,  so  that  the  incision  ends 
three  inches  above  the  pubes.  The  incision  should  be  made 
deliberately,  and  all  bleeding  vessels  secured  by  pressure  forceps. 
When  the  more  superficial  tissues  are  divided,  the  division  between 
the  recti  muscles  is  sought  for  and  the  incision  made  through  it. 
When  the  peritoneum  is  reached,  after  the  sub-peritoneal  fat  is  cut 
through,  a  small  portion  is  pinched  up  with  dissectmg  forceps  and 
divided.  The  uterus  will  generally  lie  in  contact  with  the  surface 
through  the  whole  extent  of  the  incision.  In  some  exceptional 
cases,  however,  there  may  be  intestine  lying  in  front  at  the  upper 
part  of  the  incision.  If  on  percussion  this  has  been  ascertained  to 
be  the  case,  the  assistant  should,  at  this  stage,  place  the  palms  of 
his  hands  at  each  side  of  the  uterus,  and  press  it  as  much  as 
possible  forward  against  the  abdominal  wall.  In  extending  the 
incision  downward  close  to  the  lower  angle  of  the  wound,  it  is  a  good 
plan  to  pass  two  fingers  of  the  left  hand  as  a  director  beneath  the 
peritoneum,  so  as  to  elevate  it  somewhat,  and  thus  to  divide  it 
between  the  fingers.  If  the  bladder  should  be  dangerously  near,  it 
will  then  be  detected  by  the  tips  of  the  fingers,  and  there  will  be  no 
risk  of  wounding  it.  This  precaution  is  the  more  desirable  if 
CsBsarean  section  is  performed  after  protracted  labour,  when  the 
bladder  will  have  ascended  through  the  stretching  of  the  lower 
segment  of  the  uterus.  Some  ascent  of  the  bladder  must  be 
expected  in  all  cases  in  which  labour  is  at  all  advanced  (see 
Fig.  131,  p.  220). 

The  uterus  may  be  incised  m  situ  or  it  may  be  first  turned  out  of 
the  abdomen.      The  former  plan  has  the  advantage  that  the  length 


Caesarean   Section,   Symphysiotomy,    Etc.     907 

of  abdominal  incision  required  is  not  so  great ;  the  latter  that  it 
renders  it  more  easy  to  prevent  the  escape  of  liquor  amnii  into  the 
abdominal  cavity.  Such  escape  seems  to  be  of  little  consequence  if 
the  membranes  are  unruptured  at  the  time  of  operation.  If  they 
are  ruptured,  and  there  is  a  chance  that  there  may  have  been  septic 
contamination  of  the  interior  of  the  uterus,  it  is  advisable  to  turn 
the  uterus  out  first.  As  a  general  rule  it  is  not  necessary  to  carry 
out  any  special  compression  or  kneading  of  the  uterus,  as  the  bleed- 
ing which  occurs  is  usually  moderate  in  amount,  and  the  uterus 
often  contracts  best  when  left  alone.  If  the  bleeding  is  at  all 
profuse  it  can  at  once  be  controlled  until  contractions  can  be  set  up 
by  compression  of  the  vessels  in  the  broad  ligaments  at  either  side 
of  the  uterus.  Two  or  three  sutures  are  now  passed  through  the 
abdominal  walls  at  the  upper  part  of  the  wound,  to  be  ready  to 
close  temporarily  that  portion  of  it,  while  the  uterine  sutures  are 
being  applied. 

Up  to  this  stage  the  operation  is  to  be  performed  deliberately, 
and  all  hsemorrhage  from  the  abdominal  wound  is  to  be  stopped 
before  the  uterus  is  opened.  During  the  next  stage,  the  best  check 
upon  haemorrhage  is  to  proceed  as  rapidly  as  possible,  and  empty 
the  uterus.  The  uterus  should  be  steadied,  and  brought  as  nearly 
as  possible  into  the  middle  line  by  the  assistant  who  places  his 
hands  at  each  side  of  it.  It  should  be  remembered  that  the  uterus 
is  generally  both  inclined  and  rotated  towards  the  right  side.  The 
incision  through  the  uterine  wall  is  commenced  about  the  middle 
of  the  abdominal  wound,  and  carried  through  to  the  internal 
surface.  Then,  when  the  membranes  are  reached,  a  director,  or, 
better,  the  fingers  are  passed  in,  and  the  uterine  wall  slit  up 
in  each  direction  nearly  to  the  extent  of  the  abdominal  incision. 
If  the  child  is  at  full  term,  the  length  of  the  incision  must  be  nearly 
six  inches,  to  give  space  for  the  head  to  be  extracted  without 
difficulty. 

Haemorrhage  is  generally  only  moderate,  provided  that  the 
placenta  is  not  attached  to  the  anterior  wall,  and  therefore  is  not 
laid  open  by  the  incision.  If  the  first  incision  enters  the  placenta, 
a  good  plan  is  to  extend  the  incision  rapidly  to  the  requisite  length, 
push  the  placenta  to  one  side  or  cut  it  through,  remove  the  child, 
and  then  at  once  detach  the  placenta ;  or  the  plan,  strongly  recom- 
mended by  Gow,  may  be  followed  of  detaching  rapidly  the  placenta 
all  round  and  removing  it  before  the  child.  The  position  of  the 
placenta  cannot  always  be  determined  beforehand.  If,  however, 
the  limbs  of  the  child  can  be  plainly  felt  over  the  front  of  the 
uterus,  covered  only  by  the  thickness  of  the  uterine  wall,  it  may  be 


9o8  The   Practice  of   Midwifery. 

inferred  that  the  placenta  is  not  situated  there.  If  the  limbs  can- 
not be  distinctly  felt,  and  a  greater  thickness  appears  to  intervene, 
it  may  be  suspected  that  the  placenta  lies  in  front. 

Fiindal  Incision  of  Uterus. — The  plan  of  making  a  fundal  incision 
from  side  to  side  of  the  top  of  the  fundus  instead  of  a  sagittal 
incision  in  the  anterior  uterine  wall  was  first  suggested  by  Fritsch 
in  1897,^  and  has  been  much  practised  in  Germany.  The  advan- 
tages claimed  are  that  the  extraction  of  the  foetus  is  easier,  that  the 
placenta  is  less  likely  to  be  incised,  and  that  the  uterus  being 
turned  out  of  the  abdomen  before  incision,  the  liquor  amnii  is  less 
likely  to  escape  into  the  peritoneal  cavity.  Experience,  however, 
shows  that  the  placenta  is  incised  less  frequently  in  the  fundal 
incision  by  only  a  very  small  percentage  of  cases.  Other  advantages 
are  that  the  fundal  incision  contracts  more  than  the  anterior 
incision,  and  so  requires  less  stitching ;  and  that  the  abdominal 
incision  is  higher,  and  is  said  on  this  account  to  be  less  liable  to 
allow  a  ventral  hernia.  The  latter  point  is,  however,  doubtful. 
Against  these  advantages  are  to  be  set  the  disadvantages  that 
intestines  are  more  likely  to  become  adherent  to  the  fundal  incision, 
and  that,  if  the  uterus  becomes  fixed  to  the  abdominal  wall,  it  does 
so  at  a  higher  level.  These  disadvantages  are  on  the  whole  greater 
than  the  advantages  obtained.  If,  however,  it  is  intended  to  com- 
plete the  operation  by  removal  of  the  uterus,  the  fundal  incision 
may  have  the  advantage. 

Removal  of  the  Foetus. — As  soon  as  the  incision  into  the  uterus 
is  completed,  the  assistant  should  hook  an  index  finger  into  each 
end  of  it,  and,  by  this  means,  hold  the  uterus  forward  against  the 
abdominal  w^all,  so  as  to  prevent  liquor  amnii  and  blood  entering 
the  peritoneal  cavity,  as  far  as  possible.  If  the  membranes  are 
intact  up  to  this  point,  the  fcetus  may  be  extracted  by  the  head. 
The  membranes  are  ruptured,  and  the  hand  rapidly  passed  down 
into  the  lower  segment  of  the  uterus,  so  as  to  scoop  out  the  head. 
This  plan  has  the  advantage  of  avoiding  the  risk  of  the  uterine  wall 
contracting  round  the  neck,  and  detaining  the  after-coming  head. 
If,  however,  the  membranes  have  been  ruptured  some  time,  it  may 
be  necessary  to  extract  the  foetus  by  the  leg.  In  this  case,  the 
extraction  of  the  head  is  facilitated,  if  some  jaw  traction  is  made 
with  the  index  finger  so  as  to  flex  the  head.  The  funis  is  tied  and 
divided,  and  the  child  handed  over  to  the  assistant  who  is  prepared 
to  attend  to  it. 

1  Zent.  f.  Gynak.,  1897,  No.  20.  See  also  Munro  Kerr  :  "  Fritsch's  Fundal  Incision," 
Journ.  of  Obst.  and  Gyn.  Brit.  Emp.,  July,  1902,  Vol.  II.,  No.  1,  p.  21  ;  Gow,  Harveian 
Lectures,  1907. 


Csesarean   Section,    Symphysiotomy,    Etc.     909 

The  next  step  is  to  turn  the  uterus  out  through  the  abdominal 
wound,  in  order  to  render  it  more  accessible  for  the  placing  of 
sutures,  and  to  stimulate  it,  if  necessary,  by  pressure  to  contract. 
A  large  flat  pad  is  placed  to  hold  back  the  intestines,  and  the  upper 
part  of  the  abdominal  wound  temporarily  closed  by  placing  catch 
forceps  on  the  sutures  already  applied  there.  Another  flat  sterilised 
pad  is  then  placed  behind  the  uterus,  to  prevent  its  coming  into 
contact  with  the  skin. 

The  uterus  is  then  stimulated  to  contract  by  kneading,  or,  if 
necessary,  by  the  aj)plication  of  a  pad,  dipped  in  hot  sterilised 
water.  The  placenta  and  membranes  must  then  be  carefully  and 
completely  detached,  and  especial  care  must  be  taken,  if  labour  has 


Fig.  450. — Diagram  of  mode  of  applying  sutures  in  Sanger's  operation. 
a.  Peritoneum  ;  1),  Muscularis  ;  c,  Mucosa ;  d,  Superficial  suture  ;  e,  Deep  suture. 


begun  and  the  membranes  have  ruptured,  that  no  portion  of  the 
latter  is  left  attached  to  the  lower  uterine  segment. 

Uterine  Sutures. — The  muscular  wall  of  the  uterus  is  to  be 
closed  by  about  twelve  deep  sutures  which  approximate  to,  but  do 
not  include  the  mucous  membrane,  and  about  double  that  number 
of  superficial  sutures  uniting  the  peritoneum  in  such  a  way  as  to 
fold  it  into  the  incision,  and  bring  flat  surfaces  of  it  into  contact 
(Fig.  450). 

There  appears  to  be  no  real  objection  to  the  plan,  adopted  by 
some  operators,  of  including  the  whole  thickness  of  the  uterine  wall 
with  the  mucosa  in  the  grasp  of  the  sutures,  but  on  the  whole  the 
plan  of  avoiding  the  mucosa  is  the  better  one. 

In  Sanger's  original  operation,  in  order  to  secure  this  end,  the 
peritoneum  was  firsb  undermined  and  separated  from  the  muscularis 
by  passing  a  scalpel  under  it  about  \  inch.  Then  a  wedge-sbaped 
strip  of  the  muscularis  was  excised  along  each  side  of  the  wound,  the 
broader  end  of  the  wedge  ]>eing  outermost,  in  order  to  allow  the 


9IO 


The  Practice  of   Midwifery. 


detached  edge  of  the  peritoneum  to  overlap  into  the  wound.  It  has 
been  found  that  both  of  these  proceedings  are  unnecessary,  and  that 
the  peritoneum  is  generally  loose  enough  to  draw  over  the  edge 
without  any  separation. 

Silver  wire,  sterilised  silk,  or  chromic  catgut,  may  be  used  for 


Fig.  451. — Diagram  of  sutures  secured  in  Sanger's  original  operation. 
a,  Peritoneum  ;  &,  Muscularis  ;  c,  Mucosa  ;  d,  Superficial  suture  ;  e,  Deep  suture. 

the  deep  sutures.  The  two  latter  are  more  convenient  for  manipu- 
lation, and  do  not  interfere  with  any  future  Csesarean  section.  I 
have  found  boiled  silk,  No.  2  Chinese  twist  for  the  deep  sutures, 


Fig.  452. — Application  of  sutures  in  Csesarean  section. 


and  No.  1  for  the  suj)erficial,  answer  excellently.  The  sutures 
should  be  ready  beforehand,  cut  of  suitable  length,  and  care 
should  be  taken  that  the  loops  to  be  left  are  not  touched  by  the 
fingers. 

For  the  control  of  haemorrhage  and  for  the  ease  of  the  application 
of  sutures,  the  edges  of  the  wound  are  everted  and  held  compressed 


Caesarean  Section,   Symphysiotomy,    Etc.     911 


by  the  assistant,  as  shown  in  Fig.  452.  Curved  needles,  forming 
an  arc  of  a  circle,  should  be  used  for  the  deep  sutures,  so  that  they 
may  be  inserted  not  far  from  the  edge  and  yet  may  include  plenty 
of  tissue  (see  Fig.  451).  In  inserting  them  the  peritoneum  should 
first  be  drawn  over  the  edge  of  the  wound  by  dissecting  forceps, 
into  the  position  which  it  is  to  occupy. 

As  already  mentioned,  the  sutures  do  not  include  the  mucosa,  so 
that  they  may  not  be  exposed  in  the  uterine  cavity,  nor  conduct 
any  septic  material  thence  to  the  peritoneum.  The  first  suture 
bisects  the  incision,  to  make  sure  that  the  edges  are  not  adapted 
unevenly.  Each  half  may  be  again  bisected  by  another  suture, 
and  two  more  sutures  placed  in  each  resulting 
quarter.  The  superficial  sutures  should  be  of 
fine  silk  (No.  1  Chinese  twist),  and  may  be  applied 
with  a  smaller  curved  needle.  In  the  original 
Sanger  suture,  each  superficial  suture  pierces  the 
peritoneum  tissue  on  each  side,  like  a  Lembert's 
suture  (Fig.  451,  p.  910).  It  is  perhaps  better 
to  pierce  the  peritoneum  twice  on  one  side  and 
once  on  the  other,  and  thus  produce  a  sero-fibrous 
and  not  a  sero-serous  union  of  the  peritoneal 
edges.  In  Figs.  450,  451,  are  shown  diagram- 
matically  the  sutures  in  section,  before  and  after 
tightening.  It  must  be  remembered  that  the 
deep  and  superficial  sutures  do  not  lie  really  in 
the  same  plane,  but  that,  generally,  two  super- 
ficial sutures  intervene  between  each  pair  of  deep 
ones.  All  the  sutures  should  first  be  placed,  then 
the  deep  ones  twisted  or  tied,  the  ends  cut  rather 
short,  if  silver  wire  is  used,  and  turned  down  into 
the  line  of  incision,  and  finally  the  superficial  sutures  tied.  If,  how- 
ever, bleeding  from  the  cut  surfaces  is  not  completely  controlled, 
the  deep  sutures  may  be  tied  before  the  superficial  are  inserted.  If 
at  any  point  the  peritoneum  does  not  come  perfectly  into  apposition, 
more  superficial  sutures  must  be  applied. 

Before  the  sutures  are  tightened,  the  finger  should  be  passed 
down  through  the  cervix,  to  make  sure  that  drainage  into  the 
vagina  is  clear.  Before  the  uterus  is  returned  into  the  abdomen, 
its  peritoneal  surface  may  be  sponged  over  with  sterile  water  or 
sterile  salt  solution.  Although  this  method  of  placing  superficial 
sutures  on  the  plan  of  Lembert's  intestinal  suture  has  seemed  to 
be  the  most  essential  part  of  Sanger's  operation,  several  operators 
have  now  discarded  it  for  the  sake  of  greater  rapidity  in  the  operation. 


Fig.  4.53. — Sutures 
tied  according  to 
Sanger's  method 
seen  from  above. 


912         '      The   Practice  of   Midwifery. 

They  simply  place  numerous  deep  sutures,  tie  them  up,  and 
then  add  superficial  or  half- deep  sutures  to  unite  the  peritoneum 
at  any  points  where  it  does  not  seem  to  be  thoroughly  brought  into 
contact.  The  result  of  this  appears  to  be  equally  satisfactory.  As 
many  as  three  deep  sutures  to  the  inch  should  then  be  used.  Complete 
contraction  and  retraction  of  the  uterus  is  now  obtained,  if  neces- 
sary, by  kneading  or  the  application  of  a  hot  sponge,  and  the  uterus 
returned  into  the  abdominal  cavity.  The  next  step  is  to  sponge  any 
blood  or  liquor  amnii  out  of  the  peritoneal  cavity,  especially  the 
pouch  of  Douglas,  by  passing  down  gauze  sponges,  held  in  sponge 
forceps,  or  a  metal  sponge  holder,  into  its  dependent  parts.  Care 
is  required  in  closing  the  abdominal  wound  to  avert  the  risk  of 
future  ventral  hernia.  Most  operators  use  three  tiers  of  sutures, 
a  buried  suture  for  the  peritoneum,  a  buried  suture  for  the  muscle 


===-^=.^LQ  t--.    --==^z? Skin. 

/  \  Fat. 

„  ^     ><^_     .  Fascia. 

"     ~—   Peritoneum. 
Fig.  454. — Author's  method  of  placing  sutures  to  unite  abdominal  wall. 

and  fascia,  and  superficial  sutures  for  the  skin,  or  skin  and  fat. 
Another  method  is  that  of  employing  through  and  through  sutures, 
as  is  shown  in  Fig.  454.  Three  sets  of  sutures  are  used, 
of  which  one  is  devoted  to  the  fascia  superficial  to  the  rectus 
muscles.  The  union  of  this  fascia  is  at  once  the  most  important 
for  the  prevention  of  hernia,  and  the  most  difficult  to  secure,  since 
it  is  retracted  laterally  owing  to  its  attachment  to  the  transversalis 
and  oblique  muscles. 

A  flat  pad  of  suitable  size  is  first  placed  under  the  abdominal 
wall  to  keep  back  intestines  and  catch  any  blood  which  flows  from 
the  punctures.  A  pair  of  catch  forceps  is  attached  to  it,  to 
remind  the  operator  that  it  has  to  be  withdrawn. 

The  first  set  consists  of  interrupted  sutures  of  stout  fishing  gut, 
and  is  passed  through  everything,  including  peritoneum,  muscle, 
fascia,  subcutaneous  fat,  and  skin.  Straight  needles  4  inches  long 
are  used.  The  needle  is  first  passed  from  the  skin  inwards  on  one 
side,  and  then  from  the  peritoneum  outwards  on  the  other. 


Caesarean  Section,   Symphysiotomy,   Etc.     913 

The  second  consists  of  a  continuous  buried  suture  uniting  the 
fascia.  The  best  material  for  this  is  gossamer  fishing  gut,  which 
may  be  obtained  in  lengths  of  18  inches.  In  the  absence  of  this 
chromic  catgut  or  fine  silk  may  be  used.  But  silk  sometimes 
becomes  contaminated  with  pus  microbes,  and  suppurates  even 
after  a  considerable  interval.  If  it  does  so,  the  whole  length  of 
suture  has  to  come  away.  When  the  buried  suture  is  approaching 
completion,  the  pad  lying  beneath  is  removed,  and  the  deep  sutures 
are  drawn  up  tight,  to  be  tied  as  soon  as  the  buried  suture  is 
completed. 

Finally  the  skin  is  united  by  a  continuous  suture  of  horsehair 
which  passes  beneath  the  loops  of  the  deep  sutures. 

A  dressing  of  sterilised  or  cyanide  gauze  is  placed  over  the 
wound,  and  secured  by  strapping.  Over  this  is  placed  a  large  flat 
pad,  and  then  a  many-tailed  bandage  of  flannel  or  swansdown 
calico,  the  tails  being  secured  together  by  safety-pins.  The 
dressing  may  generally  be  left  untouched  seven  days.  The  deep 
sutures  should  be  left  ten  days.  But  if  a  few  are  causing  inflamma- 
tion through  tightness,  these  may  be  removed  at  seven  or  eight  days. 
The  superficial  suture  should  be  left  two  or  three  days  longer. 

Opinions  differ  as  to  the  propriety  of  rendering  the  patient 
sterile  for  the  future.  Many  cases  are  now  on  record  of  a  patient 
passing  safely  through  two  Csesarean  sections,  and  a  few  of  even  three 
or  more  successful  operations  on  the  same  patient.^  If  the  line  of 
incision  in  the  uterus  becomes  adherent  to  the  abdominal  wall,  as 
is  sometimes  the  case,  at  a  second  operation  the  uterus  may  be 
opened  without  any  opening  of  the  peritoneal  cavity,  and  the  risk 
of  the  operation  is  then  less  than  usual.  I  have  met,  however, 
with  a  case  in  which  there  was  no  such  adhesion,  and  in  which 
the  line  of  union  in  the  uterus  ruptured  during  labour.  The  foetus 
escaped  into  the  abdomen,  and  the  patient's  life  was  only  saved  by 
the  placenta  sticking  in  the  rent  and  forming  a  plug.  I  removed 
foetus,  placenta,  and  uterus  by  abdominal  section  a  week  after  the 
accident  with  a  successful  result. 

Now  that  the  results  of  Caesarean  section  are  so  favourable,  the 
patient  may  be  advised  to  face  the  risks  of  future  pregnancy  if 
she  is  in  a  position  to  obtain  the  best  operative  skill  when  the 
occasion  arrives.  But,  even  at  the  best,  the  risk  is  about  ten 
times  that  of  a  normal  delivery  ;  and,  if  the  patient  prefers  not  to 
run  that  risk,  it  is  right,  in  my  opinion,  that  the  option  should  be 
allowed  to  her. 

If  it  is  decided  to  render  the  patient  sterile,  there  is  a  choice 

1  Wallace,  Jouni.  Obstet.  and  Gyn.  Brit.  Emp.,  1902,  Vol.  II.,  No.  6,  p.  555. 
M.  58 


914  ^     The   Practice  of   Midwifery. 

between  removal  of  the  uterus,  one  or  both  ovaries  being  left,  and 
other  modes  of  procuring  sterility.  I  have  several  times  chosen 
the  former  with  a  favourable  result,  in  order  to  avoid  the  risk  of 
contamination  of  the  peritoneum  from  the  uterus.  But  the 
operation  is  rather  more  severe,  and  there  is  not  yet  sufficient 
evidence  to  show  whether  the  mortality  is  less  or  greater.  If,  how- 
ever, there  is  reason  to  fear  that  septic  infection  of  the  uterus  has 
occurred,  hysterectomy  should  be  chosen. 

Pregnancy  has  occurred  notwithstanding  the  tying  of  the 
Fallopian  tubes,  and  even  the  removing  of  a  portion  of  them.  But 
it  appears  to  be  a  fairly  certain  method  to  place  two  ligatures  on 
each  tube,  remove  a  piece  of  the  tube  between  them,  and  then 
cut  out  in  conical  shape  the  mucous  membrane  of  the  piece  of 
tube  left  attached  to  the  uterus,  and  close  the  orifice  by  a  suture, 
the  peritoneum  being  sewn  together  over  the  stump. 

After-treatment. — The  after-treatment  is  the  same  as  that  after 
abdominal  section  in  general.  The  patient  is  kept  on  her  back,  a 
pillow  being  placed  under  the  knees,  and  perfect  quiet  is  main- 
tained. Morphia  should  be  avoided  if  possible,  but  an  enema 
containing  potassium  bromide  40  grains  and  mucilage  of  starch 
four  ounces  may  be  administered  and  repeated  two  or  three  times, 
at  intervals  of  four  hours,  if  necessary,  to  relieve  pain  and  soothe 
the  patient.  The  catheter  should  be  used  if  required,  but  if  the 
patient  can  pass  urine  herself  it  is  better. 

For  about  twenty  hours  after  the  operation  nothing  should  be 
given  by  the  mouth  except  hot  water,  one  or  two  ounces  at  a  time. 
At  the  end  of  this  time,  food  may  be  commenced,  at  first  only 
about  an  ounce  every  hour.  Milk  and  barley  water,  equal  parts, 
may  be  given  at  first,  or,  if  this  does  not  suit,  Benger's  or  Neave's 
food,  made  thin,  or  peptonised  milk.  After  three  days  tea,  custard, 
jellies,  junkets,  or  bread  and  milk  may  be  given,  and  fish  com- 
menced after  four  or  five  days.  If  there  is  shock  or  excessive 
haemorrhage  at  the  operation  a  quart  of  normal  saline  solution 
should  be  injected  j)er  rectum  before  the  patient  has  recovered  from 
the  anaesthetic.  In  case  of  thirst  a  pint  of  warm  water  with  a 
saltspoonful  of  salt  may  be  given  occasionally  by  enema.  In  case 
of  prolonged  vomiting  nutrient  enemata  should  be  given,  and  it  is 
a  useful  plan  in  such  cases  to  wash  out  the  stomach  with  a  stomach 
tube.  In  many  cases  the  patient  is  able  to  suckle  her  infant,  and 
the  lactation  aids  the  contraction  and  involution  of  the  uterus.  In 
general  the  patient  may  leave  her  bed  at  the  end  of  three  weeks. 
Vaginal  douches  are  not  essential  after  the  operation  if  the  patient 


Caesarean   Section,    Symphysiotomy,   Etc.     915 

is  doing  well,  especially  if  the  vulva  is  kept  occluded  by  sterilised 
pads.  In  case  of  offensive  discharge  from  retention  of  clots  in  the 
uterus  it  may  be  necessary  to  wash  out  the  uterus  with  a  Budin's 
double- action  catheter.  In  general  the  lochial  discharge  is  less 
abundant  than  the  average.  If  douches  are  used  at  all,  one  of 
the  least  poisonous  antiseptics,  such  as  chinosol  1  in  500,  cyllin 
1  in  100,  or  Tr.  lodi  5ij.  ad  Oj.,  should  be  used  with  boiled  water, 
and  the  douches  should  be  given  by  means  of  an  irrigator  only 
slightly  elevated. 

Suprasymphyseal  or  Extraperitoneal  Caesarean  Section. — 
With  a  view  to  avoiding  the  handling  of  the  uterus  which  the 
classical  operation  involves  and  the  danger  of  septic  infection  of 
the  peritoneum  when  the  aseptic  condition  of  the  interior  of  the 
uterus  is  doubtful,  Frank  ^  has  devised  an  extraperitoneal  operation 
designed  to  minimise  the  risk  of  hgemorrhage  and  of  peritonitis 
and  to  allow  of  the  performance  of  the  operation  late  in  the  first 
stage  of  labour.  His  method  has  been  modified  by  Sellheim  and 
others,  but  the  operation  as  generally  performed  is  as  follows : — 
The  skin  and  fat  are  divided  by  a  transverse  incision  just  above 
the  symphysis  pubis,  and  the  fascia  and  muscles  are  divided  longi- 
tudinally in  the  middle  line.  The  muscles  are  separated  and  the 
retro-pubic  cellular  tissue  exposed.  The  peritoneum  is  then  care- 
fully strip]3ed  up  from  the  superior  surface  of  the  bladder  and  from 
the  anterior  surface  of  the  uterus,  and  is  pushed  up  while  the 
bladder  is  pushed  down.  In  this  way  the  anterior  surface  of  the 
lower  segment  of  the  uterus  is  exposed  extraperitoneally.  This  is 
opened  by  a  vertical  or  transverse  incision,  and  the  child's  head  is 
made  to  present  in  the  wound  by  pressure  exerted  upon  the  uterus. 
The  foetus  may  be  extracted  by  traction,  by  forceps,  or  if  necessary 
by  version. 

By  some  operators  the  peritoneal  cavity  is  opened,  and  the 
peritoneum  over  the  bladder,  having  been  incised,  is  stripped  up  to 
a  sufficient  extent  and  sutured  to  the  parietal  peritoneum  at  the 
upper  margin  of  the  wound.  Another  modification  is  to  cut 
through  the  peritoneum  and  to  separate  the  bladder  from  the  side 
instead  of  turning  it  down,  and  so  expose  the  anterior  surface  of 
the  lower  uterine  segment.  By  this  operation  the  danger  of 
infection  of  the  peritoneum  is  avoided,  and  it  is  claimed  that  the 
incision  into  the  lower  segment  can  be  sutured  more  easily  and 
more  rapidly,  and  that  it  is  less  likely  to  cause  severe  haemorrhage. 

1  Arch.  f.  Gyatik.,  1907,  Bd.  81,  lift.  1,  p.  46. 

58—2 


9i6         '      The  Practice  of   Midwifery. 

In  order  that  the  operation  may  be  readily  carried  out,  the  first 
stage  of  labour  should  be  well  advanced  and  the  cervix  fully  dilated. 

In  cases  where  the  uterus  is  definitely  infected  Sellheim  ^  recom- 
mends that  after  delivery  of  the  child  the  edges  of  the  incision  in 
the  lower  uterine  segment  should  be  united  to  the  edges  of  the 
abdominal  incision,  and  that  this  utero-abdominal  fistula,  as  he 
terms  it,  should  be  left  open  and  allowed  to  close  spontaneously  or 
be  closed  finally  by  a  plastic  operation. 

Doderlein  ^  practises  a  somewhat  similar  operation,  in  which,  by 
raising  the  peritoneum  at  the  pelvic  brim,  he  obtains  access  to  the 
lateral  extraperitoneal  portions  of  the  uterus  without  detaching  the 
bladder. 

Post-mortem  Csesarean  Section. — When  a  pregnant  patient 
dies,  and  the  child  is  living  and  viable,  it  is  right  for  the  physician, 
with  the  permission  of  the  friends,  to  perform  Cesarean  section,  in 
order  to  save  the  child.  There  are  mythical  stories  of  children 
having  been  saved  in  this  way  hours  after  the  mother's  death.  In 
point  of  fact,  however,  the  child  does  not  remain  capable  of  resusci- 
tation for  many  minutes  after  her  death.  After  more  than  fifteen 
minutes  it  is  probably  useless  to  perform  the  operation.  If, 
therefore,  it  is  to  be  of  any  avail,  the  practitioner  must  be  present 
at  the  time  of  the  death,  and  he  should  obtain  the  consent  of  the 
friends  beforehand.  He  must  also  operate  with  whatever  instru- 
ments he  has  on  the  spot.  A  penknife  or  razor  has  been  used  in  the 
absence  of  more  convenient  implements.  The  incisions  and  mode  of 
extraction  are  the  same  as  in  ordinary  Cesarean  section.  The  child, 
if  alive  at  all,  will  probably  have  to  be  restored  by  artificial  respira- 
tion. If  death  takes  place  during  labour,  when  the  os  is  already 
fairly  dilated,  it  will  be  preferable  to  extract  the  child  rapidly  by 
version  or  forceps. 

PoRRo's  Operation. 

In  Porro's  operation,  the  main  part  of  the  uterus  is  removed, 
and  the  danger  of  having  a  uterine  wound  communicating  with 
the  peritoneal  cavity  is  thus  avoided. 

Porro,  of  Pavia,  having  devised  his  method,  and  tested  it  by 
successful  experiments  on  animals,  carried  it  out  first  in  1876  on 
a  patient  having  a  rachitic  pelvis  with  a  conjugate  diameter  of 
1^  inch.  This  patient  recovered ;  and  for  some  time  a  consider- 
able  number  of   Porro  operations  were  performed,  especially  in 

1  Miinchener  Med.  Wochenschr.,  1908,  No.  42,  p.  2207  ;  Zentralbl.  f.  Gyniik.,  1908, 
No.  20,  p.  641. 

2  Doderlein,  Zentralbl.  f.  Gyn.,  1909,  No.  4,  p.  121. 


Caesarean   Section,   Symphysiotomy,   Etc.     917 

Italy  and  Germany.  The  term  Porro's  operation  is  now  often 
extended  to  the  more  modern  variety  of  supra-vaginal  hysterectomy, 
in  which  the  pedicle  is  dropped  within  the  pelvis.  The  original 
Porro  operation  will  first  be  described. 

Porro's  Operation  with  External  Fixation  of  Pedicle. — The 
steps  of  the  operation  are  the  same  as  in  ordinary  Cesarean  section 


Fig.  455. — Koeberle's  serre-nceud. 


Fig.  456. — Guarded  pin 
for  fixing  stump  of 
uterus  in  abdominal 
wound. 


up  to  the  incision  in  the  uterus.  It  is  of  little  consequence  in 
what  direction  this  incision  is  made,  since  it  is  to  be  removed  with 
the  uterus.  If,  therefore,  it  is  concluded  that  the  placenta  is 
situated  on  the  anterior  wall,  the  uterus  may  be  first  turned  out, 
and  an  incision  on  the  posterior  wall,  or  Fritsch's  fundal  incision, 
made.  As  soon  as  the  foetus  is  removed,  haemorrhage  from  the 
uterine  wound  should  be  temporarily  checked  by  an  elastic 
ligature.     The  placenta  may  then  be  left  in  the  uterus,  and  the 


91 8  The  Practice  of   Midwifery. 

remaining  steps  of  the  operation  carried  out  deliberately  without 
haemorrhage. 

The  rest  of  the  operation  is  similar  to  the  method  of  hyste- 
rectomy, which  was  formerly  employed  for  the  removal  of  the 
uterus  enlarged  by  fibroid  tumour,  the  cervix  being  clamped  as  a 
pedicle  in  the  abdominal  wall.  The  uterus  is  drawn  out  through 
the  abdominal  wound,  the  intestines  being  kept  back  by  an  assis- 
tant, and  covered  with  a  large  flat  sponge  or  sterilised  pad.  A 
Koeberle's  serre-noeud  (Fig.  455),  an  instrument  like  a  short 
ecraseur,  is  fitted  with  a  loop  of  thick  soft  iron  wire,  or  what  is 
better,  with  a  wire  of  "delta  metal,"  one  end  of  the  loop  fixed  to 
the  moving  button,  the  other  end  free.  This  loop  is  passed  round 
the  lower  part  of  the  uterus  and  adjacent  portions  of  the  broad 
ligaments,  so  that  it  passes  below  the  lower  end  of  the  uterine 
incision.  It  is  preferable,  if  possible,  to  leave  one  or  both  ovaries. 
In  order  to  do  this,  a  ligature  may  be  placed  upon  the  ovarian 
artery  above  the  ovary,  and  the  broad  ligament  divided  above  the 
ligature,  a  clamp  being  placed  on  the  distal  part  of  the  vessel.  The 
free  end  of  the  loop  is  now  seized  with  a  pair  of  pliers,  drawn  up 
prett}'  tightly  and  twisted  round  the  button.  The  screw  of  the 
serre-noeud  is  then  turned  till  the  wire  is  tight  enough  to  stop 
haemorrhage,  but  not  tight  enough  to  cut  the  tissues.  The  uterus 
is  then  cut  away  about  an  inch  above  the  loop.  If  there  is  any 
bleeding  at  this  time  from  the  stump,  a  little  further  tightening 
of  the  serre-noeud  will  stop  it.  It  is  important  for  success  that  the 
circulation  beyond  the  loop  should  be  completely  cut  off. 

The  stump  of  the  uterus  has  next  to  be  fixed  as  a  pedicle  in  the 
lower  angle  of  the  abdominal  wound.  Two  guarded  pins  (Fig.  456) 
are  passed  transversely  through  the  pedicle  just  above  the  loop  of 
wire,  so  that  the  ends  lie  on  the  abdominal  walls,  and  keep  the  cut 
surface  of  the  pedicle  outside,  the  wire  loop  lying  in  a  depression 
just  below  the  pins.  These  pins,  like  the  wires,  are  now  made  of 
delta  metal,  which  does  not  rust  or  corrode.  Large  strong  hare-lip 
pins  might  be  used,  in  the  absence  of  pins  specially  constructed. 
The  abdominal  sutures  are  then  applied  in  the  usual  way  above 
the  pedicle,  special  care  being  taken  in  the  adjustment  of  the 
lowest  suture,  so  that  it  may  bring  the  cut  edges  of  the  peritoneum 
into  contact  with  the  pedicle  of  the  uterus  all  round,  and  with 
each  other  immediately  above  the  stamp.  At  this  spot  a  buried 
suture  of  fine  silk  may  be  used,  uniting  the  two  edges  of  parietal 
peritoneum  to  the  pedicle  on  the  proximal  side  of  the  wire.  It  is 
well  to  place  also  one  suture  in  the  angle  of  the  wound  below  the 
pedicle,  so  as  to  infold  the  edges  of  the  peritoneum  there  also. 


Caesarean   Section,    Symphysiotomy,   Etc.     919 

In  the  absence  of  the  serre-noeud,  the  operation  may  be  carried 
out  effectively  by  the  permanent  use  of  the  elastic  ligature.  The 
ligature  is  tied  tightly  round  the  lower  part  of  the  uterus,  and  the 
pins  are  passed  through  immediately  above  the  ligature.  Knitting 
needles  may  be  used  for  pins,  and  ordinary  drainage  tubing  for 
elastic  ligature  ;  and  thus  the  operation  may  be  performed  without 
any  special  appliances. 

Dressing  the  Wound. — The  short  stem  of  the  serre-noeud  is 
to  be  enclosed  in  the  antiseptic  dressings.  The  layers  of  gauze 
coveiring  the  abdomen  may  be  slit  up  to  some  distance  from  below 
so  that  the  stem  of  the  ecraseur  passes  through  the  slit.  Then  a 
transverse  layer  of  gauze  is  laid  across  below  the  stem,  and  the 
instrument  itself  is  wrapped  round  with  strips  of  gauze.  The  key 
of  the  serre-nceud  (see  Fig.  455,  p.  917)  is  kept  at  hand,  so  that 
in  case  there  is  any  haemorrhage  from  the  stump,  the  nurse  may 
be  able  to  stop  it  at  once  by  giving  a  turn  to  the  screw.  In 
other  respects,  the  dressings  are  the  same  as  for  ordinary  Csesarean 
section. 

After-treatment. — The  wound  should  be  looked  at  the  day 
after  operation  ;  and  the  serre-noeud  tightened,  if  there  is  any  sign 
of  vascularity  in  the  stump.  It  becomes  dry  and  leathery  on  the 
surface  if  circulation  is  properly  arrested.  The  strangled  portion 
of  the  pedicle  may  separate  about  the  twelfth  or  fourteenth  day, 
leaving  a  depression  in  the  abdominal  wall.  Decomposition  of  the 
pedicle  will  have  begun  before  this.  As  soon  as  it  does  so,  the 
pedicle  must  be  dressed  daily  or  twice  a  day,  and  may  be  dusted 
each  time  with  iodoform  or  aristol.  Any  redundant  portions  may 
be  cut  away  from  time  to  time.  For  the  first  few  days  a  rather 
free  use  of  morphia  may  be  necessary,  to  relieve  pain  caused  by 
the  constriction  and  tension  of  the  stump. 

SUPEA-VAGINAL    HySTEEECTOMY. 

The  operation  is  facilitated  by  the  Trendelenburg  position, 
especially  during  the  stage  of  stitching  up  the  peritoneum.  In  the 
absence  of  a  special  table,  this  may  be  improvised  by  inverting  a 
straight-legged  chair  on  the  operating  table,  and  folding  a  mattress 
over  it. 

After  removal  of  the  foetus,  the  uterus  is  turned  out  of  the 
abdomen  and  hsemorrhage  arrested  by  an  elastic  ligature  or 
clamps  to  the  broad  ligaments  compressing  the  vessels.  Ligatures 
are  placed  on  the  ovarian  arteries,  so  as  to  preserve  one  or  both 


920  The  Practice  of   Midwifery. 

ovaries,  and  clamps  on  the  distal  portions  of  the  vessels.  Liga- 
tures are  placed  on  the  round  ligaments,  and  the  broad  ligaments 
are  then  divided  on  both  sides,  up  to  and  including  the  round 
ligaments.  Next  the  peritoneum  is  divided  in  front  from  one  round 
ligament  to  the  other,  about  an  inch  above  the  reflection  of  the 
bladder,  and  stripped  down  with  the  bladder.  The  uterine  arteries 
are  then  found  and  ligatured,  and  the  rest  of  the  broad  ligaments 
and  the  cervix  cut  across.  Any  small  vessels  which  bleed  are  tied. 
If  the  cervix  is  expanded,  and  the  cut  surface  bleeds,  it  may  be 
advisable  to  arrest  bleeding  by  inverting  and  stitching  together 
the  cut  surfaces  at  the  sides,  but  a  central  opening  should  be  left 
for  drainage.  The  peritoneum  is  then  stitched  together  over  the 
stump  by  a  continuous  suture  of  fine  silk,  so  as  to  isolate  the  peri- 
toneal cavity,  and  the  abdominal  wound  is  closed.^ 


Panhysterectomy. 

The  operation  is  the  same  as  the  last  up  to  the  stage  at  which 
the  uterine  arteries  are  tied.  They  are  exposed  by  separating  the 
two  layers  of  the  broad  ligament,  and  are  tied  as  low  down  as 
possible,  the  ureter,  in  order  to  avoid  any  risk  of  injuring  it,  being 
exposed  and  if  necessary  dissected  out.  The  bladder  is  then  stripped 
well  down  off  the  anterior  wall  of  the  cervix  and  off  the  vagina, 
and  the  two  utero-sacral  ligaments  are  clamped,  tied,  and  divided. 
The  vagina  is  then  opened  in  the  middle  line  in  front  or  at  the  side 
and  separated  all  round  from  the  cervix.  As  a  rule  there  is  some 
bleeding  from  the  cut  angles  of  the  lateral  vaginal  walls,  and  this  is 
arrested  by  ligatures  passed_by  means  of  a  needle.  Finally,  a  plug 
of  gauze  may  be  placed  in  the  vagina  and  the  peritoneal  edges 
united  over  the  plug. 

The  uterus  may  also  be  removed  by  Doyen's  method  of  pan- 
hysterectomy. In  this  operation,  the  uterus  is  drawn  forward 
over  the  pubes,  the  posterior  vaginal  fornix  is  first  opened,  the 
cervix  is  seized  with  a  vulsellum  and  pulled  forcibly  upwards,  and 
then  the  bladder  is  stripped  from  the  uterus  from  below  upwards. 
The  uterus  is  then  separated  from  below  upwards  by  incisions 
which  keep  very  close  to  the  uterine  wall.  The  cervical  vessels  are 
tied  separately,  and  the  upper  parts  of  the  broad  ligaments  are 
transfixed  and  tied  as  pedicles.  The  peritoneum  is  closed  by  a 
purse-string  suture,  and  the  vagina  can,  if  the  operator  prefer  it, 
be  plugged  below. 

1  For  a  full  description,  with  illustrations,  of  this  and  the  other  varieties  of  hysterec- 
tomy, see  Galabin's  Diseases  of  Women. 


Caesarean   Section,    Symphysiotomy,   Etc.     921 

Choice  of  Operation. — In  general  the  conservative  Sanger 
Caesarean  section  is  to  be  preferred.  The  extraperitoneal  operation 
may  be  performed  in  cases  where  the  condition  of  the  uterine 
contents  is  doubtful  or  where  they  are  certainly  septic  and  in 
aseptic  cases  as  an  alternative  to  the  classical  operation.  It  has 
also  been  suggested  as  an  alternative  to  symphysiotomy  or 
pubiotomy  in  elderly  primiparse  where  these  operations  are 
contra-indicated  on  account  of  the  rigidity  of  the  soft  parts.  The 
exact  relation  which  these  two  varieties  of  Csesarean  section  will 
bear  to  one  another  in  the  future  cannot  be  determined  at  the 
present  time.  Further  experience  of  the  results  of  the  extra- 
peritoneal operation  is  required  to  settle  this  question.  The  uterus 
should  be  removed  in  cases  of  fibroid  tumour  or  removable  cancer, 
or  if  it  refuses  to  contract  after  exhaustion  from  prolonged  labour,  or 
if  it  has  been  damaged  in  attempts  to  extract  through  the  pelvis, 
especially  if  it  is  likely  that  septic  infection  has  been  conveyed. 
Panhysterectomy  is  only  called  for  if  the  cervix  is  much  damaged 
or  infected  by  sepsis,  or  in  cases  of  removable  cancer,  or  fibroid 
tumour  of  the  cervix.  In  general  supra-vaginal  hysterectomy  is 
preferable.  The  original  Porro's  operation  has  the  disadvantages 
that  the  sloughing  of  the  pedicle  leads  to  a  slower  convalescence, 
and  a  weak  point  left  in  the  abdominal  wall ;  and  the  intra-pelvic 
treatment  of  the  pedicle  now  gives  a  less  mortality.  The  original 
operation  may  be  chosen  if  the  operator  is  inexperienced  in 
abdominal  surgery,  since  it  can  be  performed  more  easily  and 
quickly.  It  may  also  be  chosen  in  cases  of  irremovable  cancer  of 
the  cervix,  in  order  to  diminish  the  risk  to  the  patient  by  shutting 
off  the  peritoneal  cavity  from  the  uterine  wound,  which  is  apt  to  be 
contaminated  by  septic  infection  from  the  cancer. 

Vaginal  Cesarean  Section. 

This  title  is  given  to  an  operation  introduced  by  Diihrssen.  The 
patient  is  placed  in  the  lithotomy  position.  The  vulva  and  vagina 
having  been  thoroughly  cleansed,  the  cervix  is  drawn  down  by 
vulsella,  the  posterior  vaginal  wall  retracted,  and  a  longitudinal 
incision  is  made  through  the  vaginal  wall  at  the  base  of  the 
bladder.  A  transverse  incision  is  also  made  across  the  cervix  just 
at  the  reflection  of  the  bladder,  and  the  bladder  and  peritoneum 
stripped  off  from  the  front  of  the  cervix.  The  cervix  is  then 
divided  anteriorly  by  a  sagittal  incision  with  scissors  up  to,  and 
if  necessary  beyond,  the  level  of  the  internal  os.  In  cases  at  or 
near  full  term  it  may  be  necessary  also  to  incise  the  posterior  wall 


922 


The  Practice  of   Midwifery. 


of  the  cervix.  In  this  case  Diihrssen  recommends  that  a  deep 
incision  should  be  made  through  the  lateral  vaginal  wall  into  the 
ischio-rectal  fossa  on  one  or  both  sides.  The  vaginal  portion  of 
the  cervix  is  then  seized  by  two  vulsella,  drawn  forward,  and  the 
cervix  divided  in  the  middle  line  as  high  up  as  the  posterior  vaginal 
fornix.     The  posterior  vaginal  fornix  is  then  opened  transversely, 


Fig.  457. — Vaginal  Csesarean  section,  showing  the  anterior  vaginal  wall,  and 
the  anterior  lip  of  the  cervix  divided.  At  the  upper  end  of  the  incision 
between  the  two  is  seen  the  bladder  pushed  up. 


and  the  peritoneum  stripped  off  the  posterior  wall  of  the  uterus. 
If  the  cervical  canal  or  external  os  is  undilated  to  begin  with,  the 
two  incisions  together  must  give  a  length  of  at  least  4^  inches,  to 
allow  the  extraction  of  a  full-sized  foetus.  The  incisions  in  the 
anterior  and  posterior  cervical  walls  are  then  extended  as  much  as 
may  be  necessary,  the  membranes  ruptured,  and  the  child  extracted 
by  forceps  or  by  version.    If  necessary,  the  placenta  and  membranes 


Caesarean   Section,    Symphysiotomy,   Etc.     923 

are  extracted  manually,  and  the  incisions  in  the  uterus  are  united 
by  catgut  sutures.  The  incisions  in  the  vaginal  walls  are  also 
united  by  sutures,  a  small  opening  being  left  for  drainage  in  front 
of  the  cervix.  Diihrssen^  has  collected  201  cases  of  conservative 
vaginal  Caesarean  section  with  28  deaths,  13*9  per  cent.,  and  47  cases 
of  the  radical  operation  followed  by  removal  of  the  uterus,  in  46 
cases  for  carcinoma  and  in  1  case  for  sepsis,  with  5  deaths,  or 
10'6  per  cent.  Of  the  28  deaths  in  the  first  series  15  died  of 
eclampsia,  and  10  others  from  causes  not  connected  with  the 
operation. 

The  operation  has  been  performed  in  cases  of  carcinoma  of  the 
cervix,  and  in  conditions  calling  for  rapid  delivery  and  associated 
with  the  presence  of  tumours  or  with  rigidity  of  the  cervix,  inter- 
fering with  its  rapid  dilatation.  It  may  also  be  adopted  if  the 
condition  of  the  mother  very  urgently  requires  rapid  delivery  in 
eclampsia  or  in  accidental  haemorrhage  after  rupture  of  the  mem- 
branes, and  Bossi's  or  Frommer's  dilator  is  not  available.  Some 
would  also  choose  it  in  preference  to  dilatation  if  the  cervical  canal 
is  intact  and  very  rigid,  especially  if  pregnancy  has  not  reached 
seven  months.  Munro  Kerr  considers  it  the  best  method  of  rapidly 
emptying  the  uterus  in  the  early  months  of  pregnancy,  but  sees  no 
reason  to  prefer  it  to  the  abdominal  operation  in  the  later  months. 

Symphysiotomy. 

History. — The  first  recorded  case  of  symphysiotomy  was  per- 
formed by  Jean  Claude  de  la  Courvee  in  1655  on  a  patient  dying 
during  labour.  A  better-known  case  was  one  in  which  the  operation 
was  performed  by  Sigault  and  Le  Koy  in  1777.  The  result  was 
not  very  satisfactory :  for  a  vesical  fistula  formed,  and  the  bones 
did  not  unite.  The  operation  did  not  therefore  find  general  favour, 
but  Italian  operators  continued  to  perform  it  from  time  to  time. 
Between  1777  and  1846,  65  cases  were  recorded  in  Italy,  with  a 
maternal  mortality  of  32"4  per  cent,  and  a  fcetal  mortality  of 
64  per  cent.  It  was  taken  up  more  actively  in  Italy  in  1866, 
chiefly  by  Morisani  and  Novi  of  Naples.  From  1866  to 
1881,  50  cases  were  recorded,  with  a  maternal  mortality  of  20  per 
cent,  and  a  foetal  mortality  of  18  per  cent.  Between  1881  and 
1885,  however,  the  maternal  mortality  increased  to  44  per  cent. 
Of  late  years  the  mortality  has  greatly  diminished,  probably  in 
consequence  of    antiseptic  improvements  in  surgery.       Fifty-two 

1  Diihrssen,  V.  Winckel,  Jlandbuch  dcr  Gcbuilsliiilfe,  1906,  Vol.  II].,  Part  1, 
p.  575. 


924 


The   Practice  of   Midwifery. 


more  recent  Italian  cases,  up  to  1893,  gave  a  maternal  mortality  of 
2  per  cent,  and  a  foetal  mortality  of  13"4  per  cent.^ 

Since  1891  the  operation  has  been  warmly  advocated  by  Pinard 
of  Paris,  and  a  considerable  number  of  cases  have  been  performed 
in  various  countries.  According  to  Harris,  out  of  233  operations 
performed  in  various  countries  in  1892 — 1893,  the  maternal  mor- 
tality was  ll'l  per  cent.,  the  foetal  mortality  22*7  per  cent.  Of 
these,  very  few  were  performed  in  Britain,  the  majority  in  Italy, 
France,  and  Germany.  Of  275  cases  collected  by  Munro  Kerr  18 
of  the  mothers  died,  a  mortality  of  6*5  per  cent.,  and  28  of  the 
children,  a  mortality  of  10  per  cent.    This  mortality  for  the  mothers 


Half  size 
Fig.  458. — Separation  of  bones  in  symphysiotomy. 


is  about  the  same  as  that  of  Cfesarean  section,  but  that  of  the 
children  represents  a  considerably  higher  risk,  for  Caesarean  section 
performed  at  an  early  stage  of  labour  is  almost  certain  to  save  the 
child. 

The  disfavour  with  which  the  operation  was  at  first  received  is 
explained  by  the  unfavourable  results  of  the  earlier  cases,  as 
regards  children  no  less  than  as  regards  mothers.  It  also  appeared 
theoretically  that,  in  a  flattened  pelvis,  but  little  increase  of  the 
sacro-pubic  diameter  could  be  obtained  by  dividing  the  symphysis. 
It  is  now  recognised  that  the  field  of  the  operation  is  in  moderate, 


1  See  Harris,  American  Journal  of  Medical  Sciences,  March,  1893 ;  Fasbender, 
Geschichte  der  Geburtshiilfe,  1906,  p.  867  ;  Munro  Kerr,  Operative  Midwifery,  1908, 
p.  394. 


Caesarean   Section,   Symphysiotomy,    Etc.     925 

not  in  extreme,  contractions  of  the  conjugate ;  and  that,  in  the 
puerperal  pelvis,  owing  to  the  relaxation  of  the  joints,  a  wider 
separation  of  the  pubic  bones  can  be  safely  obtained  than  appeared 
probable  d  ijriori,  or  than  would  be  possible  apart  from  pregnancy. 
Thus  the  central  mass  of  the  head  passes  in  the  gap  between  the 
separated  pubic  bones,  and  does  not  enter  even  the  enlarged  sacro- 
pubic  diameters  at  all,  as  shown  in  Fig.  458. 

Indications  for  the  Operation. — It  appears  that  the  smallest 
conjugate  for  which  the  operation  can  reasonably  be  recommended 
is  about  3  inches  (7'5  cm.)  ;  although  Pinard  considers  it  available, 
in  the  simple  flat  pelvis,  down  to  2|  inches,  and  I  have  myself 
performed  it  successfully,  though  with  considerable  laceration  of 
vagina,  with  a  conjugate  of  2J  inches.  In  Fig.  458  is  shown  the 
effect  of  the  operation  in  a  flattened  pelvis  with  slight  general 
contraction,  the  conjugate  being  2f  inches.  Allowing  \  inch  for 
soft  parts,  a  circle  of  3|  inches  diameter  will  generally  be  required 
for  the  passage  of  a  full-sized  foetal  head.  The  corresponding 
separation  of  the  pubic  bones,  as  shown  in  the  figure,  is  fully 
2f  inches,  and  the  bones  must  also  be  separated  at  the  anterior 
margins  of  the  sacro-iliac  joints  to  the  extent  of  at  least  \  inch. 

The  improved  results  of  Cgesarean  section  render  that  operation 
preferable  as  a  first  choice,  when  preparations  are  made  for  opera- 
tion before  labour.  Csesarean  section  has  also  the  advantage  that 
it  allows  the  patient,  if  she  desires  it,  to  be  rendered  sterile  in 
future,  and  free  from  the  risks  of  future  labours. 

Symphysiotomy  may  be  performed  in  the  interest  of  the  child 
in  slight  or  moderate  pelvic  contractions  when  labour  has  already 
been  prolonged,  and  attempts  to  extract  by  forceps  have  been  made 
and  failed.  In  these  circumstances  the  risk  is  likely  to  be  less 
than  that  of  Caesarean  section.  It  is  essential  that  the  child  should 
be  alive  and  uninjured,  the  cervix  fully  dilated,  and  the  size  of  the 
pelvis  such  that  there  is  a  reasonable  probability  of  a  living  child 
being  delivered  after  the  performance  of  the  operation.  It  should 
not,  however,  be  undertaken  if  there  is  reason  to  believe  that  septic 
infection  has  already  occurred,  nor  when  there  is  any  likelihood 
that  the  child  has  been  injured  by  repeated  attempts  to  deliver  with 
forceps. 

Some  authorities  recommend  that  it  should  be  practised,  in  the 
interests  of  the  mother,  when  there  is  difficulty  in  extraction  after 
craniotomy,  but  at  the  present  day  most  operators  would  prefer  one 
or  other  of  the  varieties  of  extraperitoneal  Caesarean  section. 

According  to  Pinard,    if  the  pubic  bones  are  separated  6  cm. 


926 


The   Practice  of   Midwifery. 


(2f  inches),  a  distance  which  should  not  be  exceeded,  the  measure- 
ments from  the  sacral  promontory  to  their  ends  are  increased 
15  mm,  (f  inch),  and  the  total  gain,  by  the  projection  of  the  head 
through  the  gap,  is  22  mm.,  or  |  inch.  Biermer^  found,  by 
experiments  on  puerperal  pelves,  that  separation  of  the  pelvic  bones 
to  distances  varying  from  7  to  9  cm.  caused  luxation  of  the  sacro- 
iliac joints.  Caution  must  therefore  be  used  in  carrying  the  separa- 
tion beyond  6  cm.  Doderlein^  has  calculated  that  the  area  of  the 
pelvic  brim  is  increased  from  105  to  155  qcm.  when  the  ends  of 
the  pubic  bones  are  separated  6  cm.  It  must  be  remembered  that 
the  movement  of  the  innommate  bones  is  one  of  rotation  downwards 
rather  than  outwards.^  Biermer  gives  the  following  table  ;  it  will 
be  seen  that  he  estimates  the  gain  in  the  antero-posterior  diameter 
lower  tha^j  Pinard.  It  is  also  evident  that  the  gain  in  the  trans- 
verse diameter  is  much  more  marked,  and  that  therefore  the 
operation  is  specially  suited  for  generally  contracted  pelves,  in 
which  the  transverse  diameter  forms  a  main  part  of  the  difficulty. 


Separation  at 

symphysis. 

cm. 

Increase  of 

antero-posterior  diameter, 

cm. 

Increase  of 

transverse  diameter 

cm. 

2 

•25       . 

1 

3 

•5 

1-5 

4 

•65       ,. 

2 

5 

•83       . 

2-25 

6 

.     ri 

3 

7 

.       1^4 

31 

The  operation  appears  to  be  followed  by  less  inconvenience  in 
multiparfe  than  in  primiparse,  on  account  of  the  rigidity  of  the  soft 
parts  in  the  latter.  Thus  Caruso  reports  22  cases,  in  which  all 
the  mothers  recovered,  and  20  children  were  born  alive.  Of  12 
multiparse  all  passed  through  a  normal  puerperium.  Of  the  10 
primiparae,  8  suffered  some  pathological  complication,  and  3  of  them 
had  vesical  fistulae. 


Preparations. — The  os  uteri  should  be  as  fully  as  possible 
dilated.  If  the  membranes  have  ruptured  prematurely,  and  the 
head  cannot  descend  upon  the  os  to  dilate  it,  being  arrested  above 
the  brim,  it  is  desirable  to  dilate  the  os  with  Champetier  de  Eibes' 
or  Barnes'  dilators.  The  pubes  and  labia  majora  should  be  shaved, 
and  pubes  and  vagina  disinfected  with  perchloride  of  mercury  1  in 

1  Zentralbl.  f.  Gynak.,  1892,  No.  51,  p.  993. 

2  Zentralbl.  f.  Gynak.,  1893,  No.  23,  p.  490. 

3  Sandstein,  Trans.  Obst.  Soc.  Edin.,  1902,  p.  68. 


Cassarean  Section,   Symphysiotomy,   Etc.     927 

1,000.  It  is  not  a  contra-indication  that  labour  has  been  somewhat 
prolonged,  provided  that  there  has  been  no  septic  infection  and  the 
child's  condition  is  good.  If  forceps  are  tried  first,  no  great  force 
should  be  used  with  them,  otherwise  the  child's  life  may  be 
endangered. 

Instruments.— The  instruments  required  are  scalpels,  scissors 
dissecting  forceps,  pressure  forceps,  curved  needles  and  needle- 
holder,  sutures  of  silver  wire,  fishing  gut,  and  of  chromicised  gut 
or  fine  silk,  and  a  special  symphysiotomy  knife  (Fig.  459),  or  a 
blunt-pointed  bistoury  with  cutting  edge  to  the 
end.  It  is  desirable  to  have  also  Pinard's 
registering  separator  for  the  pubic  bones,  and  a 
chain  saw.  There  should  be  three  assistants 
besides  the  anesthetist:  one  to  assist  the 
operator,  two  to  stand  at  the  sides  of  the  patient 
and  press  the  innominate  bones  together  when 
required. 

The     Operation.  —  The     operator     stands 

between   the   patient's   thighs.     An   incision   is 

made  about  3  inches  long  in  the  median  line, 

commencing    1|    inch    above    the    pubes,   and 

ending     just    above    the     clitoris    or    mclined 

laterally  at  the  side  of  the  chtoris  outside  the 

nympha.       Bleeding    points    are    secured    by 

pressure    forceps.      If   there    is    much    venous 

oozing,  as  is  often  the  case,  a  plug  of  sterilised 

gauze  should   be   packed  into   the  wound  after 

the   symphysis  has  been  divided.       The   pyra- 

midahs   and  recti  muscles   are   then   separated 

from  the  top  of  the  pubic  bones,  sufficiently  to  allow  the  operator 

to  pass  his  mdex  finger  behind  the  symphysis,  and   protect  the 

bladder  from  the  tip  of  the  knife.      The  operator  then  seeks  for 

the  symphysis  and  divides  it   from  above  downwards,    includina 

the  mferior  ligament,  with  the  curved  blunt-pointed  knife  intro" 

duced  by  Galbiati    (Fig.  459),  or   with  a   blunt-pointed   bistoury 

keeping   the   finger   between   the    knife   and   the   bladder        The 

Italian    operators,    however,   divide    the    symphysis    from    below 

upward       During  the  cutting  through  the  symphysis,   a  bladder 

sound  should  be  held  in  the  urethra,  and  should  draw  it  somewhat 

to  one  side,  the  opposite  side  to  that  to  which  the  cutaneous  incision 

has  been  made  to  incline  at  its  lower  part.     As  soon  as  the  division 


Fig.  459.— Symphy- 
siotomy knife. 


928 


The   Practice  of   Midwifery. 


is  complete,  the  bones  generally  spring  apart  suddenly  to  a  distance 
of  f — 1  inch. 

Occasionally  operators  have  failed  to  divide  the  symphysis  with 
a  knife,  and  have  been  obliged  to  have  recourse  to  a  chain  saw. 
This  has  probably  been  due,  not  to  anchylosis,  but  to  the  operator 
failing  to  find  the  symphysis,  which  is  often  not  exactly  in  the 
middle  line. 

When  the  symphysis  has  been  divided,  Pinard's  registering 
separator  (Fig.  460)  may  be  introduced,  to  aid  the  separation  and 
indicate  its  amount.  By  eversion  of  thighs,  and,  if  necessary, 
by  traction  upon  the  ilia,  a  separation  of  at  least  4  cm,  (If  inch) 

should  be  obtained  before  traction  is  com- 
menced. The  separation  of  the  bones  is 
increased  if  the  patient  is  placed  in 
Walcher's  position  (see  p.  837),  with  the 
legs  hanging  vertically  ;  and  this  position 
also  adds  to  the  increase  of  space  at  the 
pelvic  brim. 

Whenever  possible,  the  labour  should 
be  allowed  to  terminate  naturally,  and 
especially  in  primiparfe  where  the  soft 
parts  are  rigid,  or  in  multiparse  where 
they  are  still  not  readily  dilatable.  If, 
however,  there  is  any  urgency,  the  foetus 
should  be  extracted  by  forceps,  axis- 
traction  forceps  being  the  best  for  the 
purpose.  It  is  advisable  to  rotate  the 
head  if  possible,  so  that  it  is  extracted 
with  its  long  diameter  transverse,  not 
antero-posterior.  If  the  indicator  shows 
that  the  separation  of  the  pubic  bones  reaches  6  cm.,  the  assis- 
tants should  support  the  ilia  at  each  side.  If  the  head  descends 
covered  by  the  cervix,  ample  time  should  be  allowed,  and  the  rim 
of  the  cervix  pushed  back  by  the  fingers.  After  the  head  has 
passed  the  brim,  the  assistants  should  press  the  ilia  together,  and 
endeavour  to  diminish  the  separation.  Otherwise  the  anterior  part 
of  the  vagina,  unsupported  by  the  bones,  is  apt  to  tear  into  the 
wound.  Care  should  be  taken  to  draw  well  downward  toward  the 
perineum,  and  if  there  is  any  indication  of  commencing  tears  of  the 
tissues  of  the  anterior  vaginal  wall  there  should  be  no  hesitation  in 
making  free  vulvo -perineal  incisions. 

Four  deep  sutures  of  silver  or  silkworm  gut  should  be  used  to  unite 
the  tissues  in  front  of  the  pubes,  care  being  taken  not  to  nip  the 


Fia.  460. — Pinard's  register 
ing  separator  for  symphy 
siotomy. 


Csesarean  Section,   Symphysiotomy,    Etc.     929 

bladder  between  the  ends  of  the  bones,  including  the  dense  tissue 
close  to  the  bone.  I  have  drilled  the  bones  and  wired  them  together 
with  thick  silver  wire,  in  order  to  secure  perfectly  close  union 
without  further  trouble,  but  operators  have  not  generally  adopted 
this  plan.  The  rest  of  the  wound  may  be  closed  by  fishing-gut 
sutures.  Any  laceration  of  vagina,  bladder,  or  urethra  must  also 
be  closed  by  fishing-gut  or  silver  wire.  It  is  often  a  good  plan  to 
drain  the  wound  with  a  piece  of  gauze.  A  firm  belt,  if  possible  a 
canvas  belt  with  buckles,  is  placed  round  the  pelvis,  the  sutures 
are  removed  at  the  end  of  a  week,  and  the  patient  is  kept  in  bed 
at  least  three  weeks.  After  the  operation,  the  uterus  and  vagina 
are  washed  out  with  lysol,  1  per  cent.  The  same  or  a  weaker 
solution  is  used  as  a  vaginal  douche  twice  a  day.  Pinard  places  a 
tampon  of  iodoform  gauze  in  the  vagina. 

Prognosis. — The  accidents  likely  to  follow  the  operation  are 
some  interference  with  the  patient's  power  of  walking,  htemorrhage, 
injuries  to  the  bladder  and  urethra,  tears  of  the  vagina,  and  the 
occurrence  of  septic  infection.  Interference  with  locomotion  is  the 
exception.  In  37  cases  examined  subsequently  to  the  operation, 
and  recorded  by  Thies,^  there  was  no  trace  of  any  permanent  injury, 
although  even  in  cases  where  the  wound  healed  by  first  intention 
there  was  some  broadening  of  the  symphysis  in  the  majority. 

Not  one  of  Munro  Kerr's  9  cases  had  her  walking  impaired  in  the 
slightest  degree.^ 

Bleeding  from  the  numerous  veins  behind  the  symphysis  pubis 
may  be  profuse  and  troublesome  to  arrest,  is  also  difficult  at  times 
to  avoid,  and  in  one  case,  at  any  rate,  has  led  to  a  fatal  result. 
The  most  common  danger  is  that  of  injuries  to  the  bladder  or  the 
urethra;  some  of  these  are  caused  by  the  operation  itself,  but 
more  often  they  occur  during  the  extraction  of  the  child.  They 
happen  more  frequently  in  primiparse  than  in  multiparas,  and  so 
marked  is  this  that  some  operators  do  not  perform  the  operation 
in  a  primipara.  Zweifel  and  Pinard,  however,  record  65  and  100 
cases  of  symphysiotomy  respectively  without  any  injury  to  the 
bladder. 

If  tears  in  the  unsupported  tissues  of  the  anterior  vaginal  wall 
occur,  they  very  frequently  communicate  with  the  divided  ends  of 
the  bones,  so  that  the  case  is  really  one  of  a  compound  fracture, 
and  the  danger  of  suppuration  and  necrosis  is  considerable.  It  is  of 
the  utmost  importance,  therefore,  that  all  possible  means  should  be 

1  Arcliiv  f.  Gynak.,  1908,  Bd.  84,  Hft.  1,  p.  99. 

2  Munro  Kerr,  Operative  Midwifery,  p.  395. 

M.  59 


930 


The   Practice  of   Midwifery. 


taken  to  avoid  such  injuries,  and  it  is  always  best  when  possible  to 
allow  the  labour  to  be  completed  naturally. 

Thies  maintains  that  the  contention  of  Zweifel  and  Pinard  that 
there  is  a  permanent  enlargement  of  the  pelvis  after  symphysiotomy 
is  correct,  and  affirms  that  the  spontaneous  delivery  of  large  children 
occurs  more  frequently  by  50  per  cent,  after  symphysiotomy  than 
before  it.  In  14  of  the  cases  examined  by  him  there  was  a  definite 
increase  in  the  conjugate  diameter,  and  in  24  in  the  transverse 
diameter. 

Subcutaneous  Symphysiotomy. — Two  operations  of  subcu- 
taneous symphysiotomy  are  described.     Of  these  the  best  is  the  one 


Fig.  461. — Bumm's  subcutaneous  method  of  performing  pubiotomy,  the 
needle  being  introduced  from  below  upwards  under  guidance  of  the 
finger  in  the  vagina.     (Bumni,  Grundriss  der  Gcburtshilfe.) 

practised  by  Herman.^  He  uses  a  sharp  pointed  tenotomy  knife, 
which  he  introduces  through  the  mucous  membrane  opposite  the 
middle  of  the  symphysis  pubis.  After  cutting  downwards  until 
the  ligamentum  arcuatum  has  been  reached  and  divided,  the  cutting 
edge  is  turned  upward  and  the  rest  of  the  symphysis  divided.  The 
only  difficulty  experienced  as  a  rule  is  that  of  dividing  the  hga- 
mentous  fibres  at  the  top  and  the  bottom  of  the  joint,  and  this  can 
be  overcome  by  pressing  the  fibres  against  the  edge  of  the  knife. 
In  the  second,  known  as  Ayres'  operation,  a  tenotomy  knife  is 
introduced  in  front  of  the  joint  to  its  upper  end.  A  blunt  pointed 
bistoury  is  then  substituted  for  this  and  the  joint  divided  from  above 
downwards  under  the  guidance  of  a  finger  passed  into  the  vagina. 

1  Herman,  Difficult  Labour,  p.  426. 


Caesarean  Section,  Symphysiotomy,   Etc.     931 

The  first  operation  is  a  very  good  one,  and  has  given  excellent 
results  in  the  hands  of  Herman  and  Buist.  Neither  allows  the 
placing  of  sutures  to  unite  the  tissues  in  front  of  the  pubic  bones, 
but  there  is  no  evidence  that  this  is  at  all  a  serious  drawback,  nor 
does  it  appear  to  have  much  influence  in  affecting  the  subsequent 
healing. 

Pubiotomy. — Of  late  years  this  operation,  first  described  by 
Stoltz  in  1844,  has  come  into  prominence  as  an  alternative  to 
symphysiotomy.  It  is  said  to  be  attended  with  less  danger  of 
injury  to  the  bladder  and  soft  parts,  and  to  be  easier  to  perform. 
It  consists  in  dividing  the  pubic  bone  instead  of  the  symphysis 
pubis,  and  brings  about  the  same  increase  in  the  pelvic  measure- 
ments. Originally  practised  by  the  open  method  after  the  bones 
had  been  exposed  by  an  incision,  it  is  now  almost  always  per- 
formed in  a  manner  more  or  less  strictly  subcutaneous.  The 
operation  as  practised  by  Doderlein  consists  in  an  incision 
2  to  3  cm.  long  being  made  over  the  pubic  spine,  and  through 
this  the  index  finger  is  introduced  to  separate  off  the  bladder  from 
the  posterior  aspect  of  the  bone.  A  handled  needle  is  passed  down 
behind  the  j^ubis  and  made  to  emerge  on  the  outer  surface  of  the 
labium  majus ;  it  is  threaded  with  a  Gigli's  saw  and  withdrawn. 
The  bone  is  readily  sawn  through,  and  when  divided  the  ends  at 
once  separate  to  the  extent  of  two-thirds  of  an  inch  or  so.  Bumm's 
method  is  even  more  simple.  A  specially  curved  needle  is  passed 
round  the  pubic  bone  from  below  upwards  under  guidance  of  a  finger 
in  the  vagina  and  kept  as  close  to  the  bone  as  possible.  It  is  made 
to  emerge  through  the  soft  parts  at  the  upper  border  of  the  bone, 
and  is  then  threaded  with  the  saw  and  withdrawn.  Leopold  makes 
a  small  puncture  on  to  the  spine  of  the  pubes,  and  passes  the 
needle  from  above  downwards  instead  of  from  below  upwards. 

To  prevent  hsemorrhage,  after  the  bone  has  been  divided,  pressure 
is  made  on  the  two  small  punctures,  and  a  plug  is  placed  in  the 
vagina.  The  cbild  can  be  delivered  with  forceps  if  the  soft  parts 
are  fully  dilated,  but  as  a  general  rule  it  is  best  to  allow  delivery 
to  occur  spontaneously. 

It  is  difficult  at  present  to  judge  of  the  merits  of  this  operation, 
but  the  dangers  certainly  appear  to  be  less  than  those  of 
symphysiotomy. 

Doderlein^  records  294  cases  of  which  77  were  done  by  the  open 

1  Dfklei-lein,  MiiiiclicMcr  Med.  Woclienschr.,  1907,  No.  24,  s.  119.5  ;  Leopold, 
Miinchener  Med.  VVochenscbr.,  1907,  No.  40,  s.  200(1  ;  Bumm,  Zentralbl.  f.  Gyn.,  1908, 
No.  19,  p.  609. 

59—2 


932 


The  Practice  of   Midwifery. 


method.  The  mortality  of  these  was  10*1  per  cent.,  that  of  21'7 
subcutaneous  operations  4-1  per  cent.  Of  the  9  deaths  5  were  due 
to  infection,  2  to  thrombosis  and  embolism,  1  to  embolism,  and  1  to 
haemorrhage.  Leopold,  however,  records  60  cases  with  no  maternal 
mortality  and  only  4  foetal  deaths  ;  and  Bumm  has  practised 
the  operation  in  53  cases  with  only  1  death,  or  a  total  of  113  cases 


Fig,  462. — The  Gigli's  saw  in  position  for  sawing  through  the  bones. 
(Bumm,  Grundriss  der  Geburtshilfe.) 


with  1  maternal  death  (see  p.  754).  The  dangers  of  the  operation 
are  practically  the  same  as  those  occurring  after  symphysiotomy, 
but  the  after-treatment  is  simpler.  The  pelvis  is  encircled  with  a 
strong  bandage,  the  knees  are  tied  together  with  the  thighs 
adducted,  and  Bumm  recommends  the  introduction  of  a  self- 
retaining  catheter  for  a  few  days.  Healing  of  the  bones  usually 
takes  place  at  first  by  fibrous  tissue,  afterwards  by  callus. 

Of  225  cases  recorded  by  Doderlein  15,  or  6'6  per  cent.,  of  the 
children   were   born    dead,   but  in   all   these   cases    instrumental 


■   Caesarean   Section,    Symphysiotomy,   Etc.     933 

delivery  had  been  practised,  and  there  can  be  no  doubt  that 
whenever  possible  spontaneous  delivery  should  be  allowed  to  occur. 
In  spite  of  the  excellent  results  obtained  by  the  strictly  subcutaneous 
method  of  Bumm,  the  contention  that  it  is  more  likely  to  be  followed 
by  injuries  to  the  bladder  must  be  allowed.^  Undoubtedly  the 
risk  of  injury  to  the  soft  parts  both  after  symphysiotomy  and 
pubiotomy  is  greatest  in  primiparse,  and  in  this  class  of  patient 
delivery  should  never  be  completed  artificially  if  it  can  be  avoided. 
The  indications  for  the  operation  are  the  same  as  those  for 
sj'mphysiotomy,  and  the  lowest  conjugate  in  which  it  can  be 
recommended  is  one  measuring  3  inches,  or  7 '5  cm. 

1  Blacker,  Lancet,  March  19,  1910,  p.  778. 


Chapter    XXXVII. 
ACCIDENTS   DURING  AND   AFTER  LABOUR. 

EUPTUEE    AND    LaCEEATION    OF    THE    GeNITAL    CaNAL. 

Laceeation  may  take  place  at  any  part  of  the  genital  canal,  but 
the  most  important  varieties  are  ruptures  of  the  uterus  and 
adjacent  portion  of  the  vagina  which  involve  the  peritoneum, 
lacerations  of  the  cervix,  and  lacerations  of  the  perineum  and 
vulva. 

EuPTUEE  OF  THE  UtEEUS  OR  VaGINA  INVOLVING  THE  PeEITONEUM. — 

Eupture  of  the  uterus  reaching  the  peritoneum,  complete  rupture, 
is  one  of  the  most  dangerous  accidents  of  labour.  Eupture  of  the 
vagina  into  the  pouch  of  Douglas  is  closely  allied  to  it,  and  is 
frequently  combined  with  rupture  of  the  uterus  itself. 

Frequency. — The  frequency  of  rupture  of  the  uterus  has  been 
variously  estimated  at  from  1  in  1,300  to  1  in  3,403  deliveries 
(JolljO-  Ii^  the  Guy's  Hospital  Charity,  when  assistance  to  labour 
was  given  very  sparingly,  forceps  cases  being  only  about  1  in  200 
deliveries,  there  were  seven  cases  of  rupture  of  the  uterus  or 
vagina  in  23,591  deliveries,  or  1  in  3,371,  a  result  closely  agreeing 
with  that  obtained  by  Jolly  from  the  statistics  of  782,741  labours 
in  Paris.  In  the  following  ten  years,  forceps  cases  being  1  in  93, 
cases  of  rupture  of  the  uterus  or  vagina  were  only  1  in  5,098. 

Causation. — Euptuee  dueing  Peegnancy.^ — Very  rarely  rupture 
of  the  uterus  has  been  met  with  during  pregnancy.  The  majority 
of  these  cases  have  followed  either  a  Cesarean  section,^  a 
previous  rupture  of  the  uterus,  or  some  injury  to  the  uterine  wall 
during  the  performance  of  the  operation  of  curettage  or  the 
removal  of  an  adherent  placenta.  Occasionally  the  rupture  has 
followed  a  fall,  as  in  a  case  recorded  by  Phillips,^  and  in  other 
instances  the  cause  has  apparently  been  an  undeveloped  condition 
of  the  uterus. 

1  Peham,  Zentralbl.  f.  Gvnak.,  1902,  No.  4,  p.  87;  Couvelaire,  Annales  de 
Gyndcologie  et  d'Obst^t.,  1906,  Vol.  III.,  p.  148. 

2  Taigett,  Trans.  Obst.  Soc.  London,  1900,  Vol.  XLII.,  p.  242  ;  Wertheim,  von 
Winckel,  Handbuch  der  Geburtshiilfe,  Bd.  2,  Hft.  1,  p.  4C8. 

3  Phillips,  Lancet,  May  8,  1909,  p.  1320. 


Accidents  during  and  after  Labour.       935 

In  a  case  recorded  by  Leopold  ^  the  uterus  probably  ruptured  at 
the  fourth  month,  the  child  escaping  into  the  abdominal  cavity 
and  the  placenta  remaining  in  utero,  and  the  pregnancy  continued 


vter^xs 


Retraction  ring 

esoended 


Retraction 
ring 


Fig.  4C.3. — Over-distension  of  the  lower  uterine  segment  in  transverse 
presentation.     (Bumm.) 

to  term,  when  the  child  died.  Various  conditions  of  the  uterine 
muscle  have  been  described  as  present  in  these  cases,  viz.,  fatty 
degeneration,  hyaline  degeneration,  deficiency  of  the  elastic  fibres. 


1  Leopold,  Arch.  f.  Oynlik.,  ]8!)fi,  Bd.  52,  p.  :57f;. 


936  The  Practice  of    Midwifery. 

and  a  condition  of  interstitial  myositis.  In  this  variety  of  rupture 
the  tear  most  commonly  is  situated  in  the  upper  segment  of  the 
uterus,  in  contrast  to  the  variety  occurring  during  labour,  when  it 
is  usually  situated  in  the  lower  uterine  segment.  When  due  to  the 
presence  of  scar  tissue  in  the  uterine  wall  the  rupture  tends  to 
occur  in  the  later  months,  and  when  due  to  maldevelopment  of  the 
uterus,  generally  within  the  first  five  months  of  the  pregnancy. 

Spontaneous  Euptuee  during  Labour. — In  this  case  the 
rupture  is  usually  caused  by  a  violent  contraction  of  the  uterus, 
which  is  unable  to  cause  advance  of  the  foetus,  and  proves  too 
strong  for  the  resistance  of  the  thinned  portions  of  the  uterus  or 
the  vagina.  Among  predisposing  causes  are  weakness  from  mal- 
development, malnutrition,  or  possibly  fatty  degeneration,  of  the 
part  where  rupture  takes  place.  Inefficient  action  of  the  auxiliary 
muscles  also  promotes  rupture,  because  the  auxiliary  forces,  tending 
to  depress  the  whole  uterus  at  each  pain,  take  some  of  the  strain 
off  its  attachments  to  the  pelvis.  Laxity  of  the  abdominal  walls, 
or  their  being  overloaded  with  fat,  is  therefore  also  a  predisposing 
cause.  Another  important  cause  is  obliquity  of  the  uterus.  Any 
deviation  of  the  uterus  from  the  axis  of  the  genital  canal  at  the 
level  where  the  head,  or  other  presenting  part,  is  lying,  diminishes 
the  efficacy  of  the  force  in  causing  advance  of  the  foetus.  It  is 
therefore  liable  to  evoke  a  more  vigorous  contraction  of  the  uterus 
than  would  otherwise  be  necessary  to  complete  labour.  At  the 
same  time  the  deviation  causes  a  certain  proportion  of  the  force  to 
be  uselessly  exjjended  in  pressure  on  the  opposite  wall  of  the 
genital  canal,  and  therefore  increases  the  liability  to  rupture  at  that 
part.  Thus,  if  there  is  a  deviation  of  30°,  there  is  a  useless 
pressure  on  the  opposite  wall  of  the  genital  canal  equal  to  one-half 
of  the  expulsive  force. 

In  the  great  majority  of  cases  rupture  is  preceded  by  an 
excessive  stretching  and  thinning  of  the  lower  distensible  segment 
of  the  uterus.  In  very  excej)tional  cases  this  may  occur  even  in 
the  first  stage  of  labour.  Much  more  frequently  it  happens  during 
a  second  stage,  jn'olonged  in  consequence  of  obstruction  to  the 
advance  of  the  foetus.  As  previously  explained  (see  pp.  621,  622), 
the  strong  contractile  portion  of  the  uterus  gradually  retracts  over 
the  foetus,  the  retraction  ring  and  internal  os  uteri  become  more 
and  more  elevated,  and  the  distensible  part  of  the  uterus  becomes 
stretched  longitudinally  as  well  as  laterally,  and  thus  greatly 
thinned.  This  distensible  portion  consists  of  the  cervix,  and  of 
the  lower  segment  of  the  body  of  the  uterus  immediately  above 


Accidents  during  and  after  Labour.       937 


the  internal  os  which  has  to  be  expanded  to  allow  the  passage  of 
the  foetus.  The  most  frequent  causes  which  lead  to  the  over- 
stretching are  disproportion  between  the  fcetus  and  the  pelvis, 
hydrocej)halus,  and  unrecfcified  shoulder  or  transverse  i)resentations. 
The  tissue  which  gives  way  may  have  been  weakened  by  the 
effects  of  prolonged  pressure  against  the  promontory  of  the  sacrum 
or  other  part  of  the  pelvic  wall.  The  risk  of  rupture  is  of  course 
increased  if  the  action  of  the 
uterus  is  excessively  violent, 
either  in  consequence  of  great 
suscejjtibility  of  the  patient  to 
reflex  stimulus,  or  of  the  inju- 
dicious administration  of  ergot 
or  other  oxytocic  remedy. 

In  comparatively  rare  cases 
rupture  takes  place  suddenly 
and  unexpectedly  without  any 
protraction  of  labour,  or  great 
disproportion  between  the  foetus 
and  the  j)elvis.  It  must  be 
explained  in  these  cases  by  a 
sudden  and  excessively  violent 
contraction  of  the  uterus, 
probably  associated  with  some 
deviation  of  its  axis,  the 
presence  of  a  placenta  prsevia, 
scar  tissue  the  result  of  a 
XDrevious  laceration,  overstretch- 
ing of  the  uterine  wall  at  a 
previous  confinement,  or  some 
degenerative  changes  in  the 
tissues  which  give  way.  This 
may  occur  even  before  rupture 
of  the  membranes,^  and  I  have 
met  with  two  instances  in  which 

rupture  occurred  not  long  after  the  escape  of  the  liquor  amnii  and 
before  the  head  had  descended  into  the  pelvis,  in  women  who  had 
previously  borne  many  children  without  much  difficulty.  In  one 
the  accident  haj^pened  when  the  woman  was  straining  upon  a  night- 
stool,  and  there  was  reason  to  believe  that,  in  both,  the  uterus  was 
anteverted  at  the  time.  The  rupture  in  each  case  was  not  through 
any  over-distended  cervix,  but  across  the  vagina,  at  its  Junction  with 

1  Ooldner,  MoimlsHchr.  f.  Geburts.  u.  Gyn.,  I'JDH,  P.d.  IH,  p.  491. 


Fig.  464. — Eupture  of  cervix  and  lower 
uterine  segment.  Breech  presentation, 
spontaneous  delivery ;  tear  probably 
caused  by  after-coming  chin.  (Univ. 
Coll.  Hosp.  Med.  School  Mus.) 


938  The  Practice  of   Midwifery. 

the  cervix.  It  is  clear  that,  in  anteversion  of  the  uterus,  when  the 
head  is  lying  above  the  brim,  on  account  of  slight  pelvic 
contraction,  esi^ecially  when  there  is  also  a  projecting  sacral  pro- 
montory, the  uterine  force  may  drive  the  head,  not  downwards  into 
the  pelvis,  but  against  the  promontory.  Wlien  rupture  takes  place 
the  head  may  be  deflected  uj)wards  by  the  promontory,  and  the  whole 
foetus  may  escape  into  the  peritoneal  cavity,  with  the  head 
uppermost. 

Traumatic  Eupture.— Eupture  may  also  be  brought  about  by 
efforts  to  deliver  artificially,  esj)ecially  by  the  attempt  to  turn  in 
shoulder  presentations  long  after  the  escape  of  the  liquor  amnii, 
or  by  the  performance  of  any  obstetric  operation  without  an 
adequate  amount  of  dilatation  of  the  cervix.  The  rupture,  in  such 
cases,  may  be  a  longitudinal  rent  extending  from  the  edge  of  the 
cervix  into  the  uterus,  or  may  take  place,  like  a  spontaneous 
rupture,  in  the  stretched  segment  of  the  uterus. 

Euptures  of  the  uterus  are  more  common  in  multiparas  than  in 
primiparge,  and  in  women  over  thirty  years  of  age  than  in  younger 
women.  The  reason  is  that,  in  multiparse,  and  in  older  women, 
laxity  of  the  abdominal  walls,  deviation  of  the  uterus,  and  degene- 
ration of  tissue  are  more  likely  to  exist.  According  to  Bandl,  only 
11  per  cent,  of  all  cases  of  rupture  occur  in  primiparte,  while 
Merz  found  in  330  cases  6  per  cent,  occurring  in  j^rimiparse. 

In  160  cases  of  rupture  of  uterus  collected  by  Merz,^  70,  or  43*6 
per  cent.,  were  due  to  contracted  pelvis ;  26,  or  16"2  per  cent.,  to 
neglected  transverse  presentations ;  21,  or  13*1  per  cent.,  to 
operative  procedures  ;  18,  or  ir2  per  cent.,  to  hydrocephalus. 

Pathological  Anatomy, — Eupture  almost  always  commences  in 
the  distended  part  of  the  uterine  wall,  the  lower  uterine  segment, 
but  it  may  extend  upwards  to  some  extent  from  this  into  the  body 
of  the  uterus.  In  some  exceptional  cases  rupture  may  commence 
in  the  body  of  the  uterus,  as  when  there  is  a  weakened  portion  of 
the  wall  in  association  with  a  fibroid  tumour,  or  when  the  cicatrix 
of  a  former  Csesarean  section  gives  wa}'.  The  initial  rupture  is 
necessarily  transverse  to  the  line  of  greatest  tension.  Thus,  in 
cases  of  hydrocephalus  or  shoulder  presentation,  when  too  bulky  a 
mass  is  forced  down  into  the  cervix,  the  line  of  rupture  is  fre- 
quently longitudinal.  Otherwise  it  is  more  generally  transverse,  or 
partly  transverse  and  partly  longitudinal,  following  an  oblique 
direction.  Eupture  may  take  place  at  any  part  of  the  uterine 
wall,  but  is  more  frequent  posteriorly  because  the  posterior  wall 

1  "  Zur  Behandlung  der  Uterus  Kuptur,"  Arch,  f.  Gyn.,  189i,  XLV.,  p.  181. 


Accidents  during  and  after  Labour,       939 

is  most  thinned,  as  shown  in  Fig.  132,  p.  221.  If  anterior,  it  may 
separate  the  uterus  from  the  bladder,  or  may  even  involve  the 
latter.^  Generally  it  extends  more  or  less  to  one  side,  involving 
the  broad  ligament.  Eupture  is  commoner  toward  the  left  side, 
because  the  occiput  is  more  often  directed  that  way,  and  because 
in  shoulder  presentation  the  head  is  more  often  to  the  left  on 
account  of  the  normal  right  obliquity  of  the  uterus.     The  rupture 


Fig.  465. — Rupture  of  cervix,  lower  uterine  segment  and  posterior  vaginal 
fornix.  Shoulder  presentation,  dead  child  delivered  by  internal  version. 
Death  forty-five  minutes  after  delivery.  (Univ.  Coll.  Hosp.  Med. 
School  Mus.) 

may  involve  the  vagina  and  the  cervix  together.  When  the  vagina 
alone  is  implicated,  the  line  of  rupture  is  generally  transverse, 
near  the  line  of  union  with  the  cervix  (Fig.  465). 

When  rupture  has  taken  place,  the  uterus  may  retract  off  the 
foetus,  expelling  the  foetus  either  partially  or  wholly  through  the 
rupture  into  the  peritoneal  cavity,  and  sometimes  the  placenta 
also.  This  is  more  likely  to  take  place  if  the  rupture  occurs 
when  the  head  is  still  above  the    brim.     The    placenta  may  be 

1  Munro  Kerr,  Operative  Midwifery,  l'J08,  p.  029. 


940 


The  Practice  of   Midwifery. 


expelled  into  the  peritoneal    cavity  when   the    foetus  is  delivered 
through  the  vulva,  or  the  converse  may  happen. 

Symptoms  and  Course  during  Pregnancy. — In  cases  occurring 
during  pregnancy  not  due  to  trauma,  there  may  at  first  be  few  or 
no  symptoms.  In  the  majority  of  these  cases,  however,  and  in 
those  occurring  early  in  labour,  the  typical  symptoms  are  present. 


Fig.  466. — Rupture  of  the  lower  uterine  segment,  with  large  subperitoneal 
hsematoma.  Flat  pelvis,  conj.  vera,  3J  inches.  High  forceps,  perforation 
and  delivery  by  cranio-tractor  at  full  term.  Death  eleven  hours  after 
delivery.    (Univ.  Coll.  Hosp.  Med.  School  Mus.) 

In  all  cases  of  obstructed  labour,  when  the  symptoms  of  this 
condition  which  have  already  been  described  (see  Chapter  XXVI.), 
are  present,  the  possibility  of  rupture  of  the  uterus  occurring  should 
be  borne  in  mind.  In  spontaneous  rupture  the  condition  is  often 
not  recognised  until  after  the  child  has  been  born. 

If  an  extensive  rupture  takes  place  suddenly,  especially  when 
the  child  escapes  through  the  tear,  the  patient  generally  feels  a 
sudden  acute  pain  and  sensation  of  tearing.  The  .pains,  which 
generally  have  been  violent  up  to  that  time,  cease  suddenly  and 
completely.   Gradually  increasing  continuous  abdominal  pain,  often 


Accidents  during  and  after  Labour.       941 

unilateral,  is  substituted  for  the  rhythmical  pains  of  labour.  The 
pulse  becomes  rapid,  and  the  anxious  face,  collapse,  and  often 
vomiting  and  extreme  pallor,  indicate  shock  and  internal  haemor- 
rhage. There  is  haemorrhage  from  the  vagina,  and  the  presenting 
part  recedes.  In  the  majority  of  cases,  when  the  foetus  is  still 
above  the  brim,  it  passes  away  out  of  reach  through  the  rent  into 
the  peritoneal  cavity. 

When  the  rupture  is  more  gradual,  being  extended  by  successive 
pains,  there  may  not  be  any  sign  making  it  obvious  exactly  when 
the  accident  has  occurred,  and  the  pains  cease  more  gradually.  In 
all  cases,  however,  when  the  rupture  is  complete,  the  pains  cease, 
there  is  haemorrhage  from  the  vagina,  and  a  rapid  pulse.  If  the 
presenting  part  is  low  in  the  pelvis,  it  may  remain  without  obvious 
recession,  but  merely  cessation  of  advance.  In  rare  cases  rupture 
has  been  found  after  spontaneous  expulsion  of  the  foetus,  having 
taken  place  in  the  final  pain. 

Diagnosis.— A  probable  diagnosis  from  the  symptoms  above 
described  is  generally  easy.  It  is  to  be  completed  by  passing  in 
the  hand  and  feeling  the  rent,  and  the  empty  uterus,  if  the  foetus 
has  escaped  into  the  abdomen.  The  outline  of  the  foetus  may  also 
be  felt  through  the  abdominal  wall  and  the  uterus  as  a  separate 
mass.  If  the  presenthig  part  still  occupies  the  vagina,  the 
diagnosis  can  only  be  made  from  the  symptoms,  until  delivery  has 
been  completed.  In  cases  occurring  during  pregnancy  a  diagnosis 
of  a  ruptured  extra-uterine  gestation  is  very  likely  to  be  made, 
while  those  occurring  early  in  labour  may  be  difficult  to  distinguish 
from  cases  of  concealed  accidental  haemorrhage. 

Prognosis. — The  prognosis  is  extremely  unfavourable.  There 
is  so  much  shock,  and  generally  such  copious  internal  haemorrhage 
from  the  rent,  that  the  patient  often  sinks  before  there  is  any 
opportunity  for  giving  surgical  aid.  Moreover,  the  repair  of  the 
rent  is  itself  often  very  difficult.  Again,  unless  abdominal  section 
is  performed,  there  is  blood  remaining  in  the  peritoneal  cavity. 
The  mortality  has  been  variously  estimated  at  from  64  to  82  per 
cent.^  The  child  is  inevitably  lost  in  all  cases  in  which  it  escapes 
through  the  rupture. 

Death  sometimes  takes  place  within  a  few  hours  from  haemor- 
rhage and  shock.  More  frequently  it  occurs  after  three  or  four 
days  from  septic  peritonitis.     The  danger  is  greater  when  the  rent 

1  Von  Walla,  Zentralbl.  f.  Gyniik.,  1900,  No.  19,  p.  .002  ;  Ivanoff,  Annales  de  Gyn. 
et  d'Obstet,  August,  1904,  p.  449. 


942         "      The  Practice  of   Midwifery. 

has  been  enlarged  by  the  passage  of  the  foetus  through  it  into  the 
abdomen. 

Prophylaxis. — The  most  important  part  of  prophylaxis  con- 
sists in  affording  timely  aid  by  forceps  or  other  means  in  all  cases 
of  obstructed  labour,  especially  when  any  contraction  of  the  pelvis 
is  discovered,  and  in  avoiding  the  administration  of  ergot  in  all 
such  cases.  The  necessity  for  timely  interference  is  especially  to 
be  borne  in  mind  when  the  pains  appear  to  be  excessively  strong, 
without  producing  any  advance  of  the  foetus.  The  patient  should 
not,  however,  be  checked  from  bearing  down  in  such  cases,  since 
the  action  of  the  auxiliary  muscles  tends  to  diminish  both  the 
thinning  of  the  lower  uterine  segment  and  the  risk  of  rupture, 
as  already  explained  (see  p.  936).  In  shoulder  presentations  and 
in  hydrocephalus  early  diagnosis  and  treatment  are  of  the  utmost 
importance.  A  useful  indication  of  danger  is  the  recognition 
through  the  abdominal  wall  in  protracted  labour  of  the  transverse 
line  of  depression  (Bandl's  ring)  at  some  height  above  the  pubes 
(see  p.  621).  If  this  is  well  marked  and  elevated  near  to  the 
level  of  the  umbilicus,  it  proves  that  the  lower  segment  of  the 
uterus  is  dangerously  thinned.  If  it  is  detected  in  protracted 
labour,  delivery  should  be  effected  at  once  with  the  least  possible 
danger  to  the  mother,  while  in  head  presentations  version  should 
be  avoided,  or  only  attempted  with  great  caution. 

Treatment. — If  the  child  remains  within  the  uterus,  the 
diagnosis  of  rupture  can  generally  be  made  only  from  the 
symptoms.  Kuj)ture  being  suspected,  the  child  should  be  extracted 
as  rapidly  as  possible.  If  extraction  with  forceps  meets  with  any 
difficulty,  craniotomy  should  be  performed  without  hesitation, 
since  the  child  is  rarely  saved  after  rupture  has  taken  place.  The 
safest  instrument  for  extraction  afterwards  is  craniotomy  forceps, 
since  the  j)osition  of  the  outer  blade  can  be  exactly  adjusted  by 
the  fingers,  while  the  cephalotribe  might  possibly  be  passed 
through  the  rupture,  and  injure  the  maternal  structures.  It  is 
well  to  keep  the  patient  in  the  dorsal  position  throughout  the 
operation,  as  well  as  afterwards.  Air  is  then  not  so  likely  to  be 
sucked  into  the  peritoneal  cavity  in  respiration,  and  less  blood 
will  gravitate  into  it. 

After  extraction  of  the  child,  the  placenta  should  be  removed 
quickly,  the  hand  being  introduced  for  the  purpose  if  necessary, 
lest  it  should  escape  into  the  peritoneal  cavity.  If  it  has  already 
done  so,  it  may  be  drawn  back  through  the  rent,  if  this  can  be 


Accidents  during  and  after  Labour.       943 

effected  easily  without  risk  of  injuring  the  intestines.  Otherwise 
the  presence  of  the  placenta  in  the  peritoneal  cavity  may  deter- 
mine the  balance  of  advantage  in  favour  of  performing  abdominal 
section,  and  removing  it  by  that  means.  The  decision  as  to  the 
best  means  of  treating  this  class  of  case  must  depend  to  a  large 
degree  upon  the  position  and  the  extent  of  the  laceration  and  the 
size  of  the  opening  by  which  it  communicates  with  the  peritoneal 
cavity. 

If  the  laceration  is  a  limited  one  and  the  opening  into  the 
peritoneum  small,  probably  the  best  treatment  is  to  apply  a  plug 
of  antiseptic  gauze  for  the  purpose  of  arresting  haemorrhage  and 
securing  drainage.  If,  on  the  other  hand,  the  tear  is  large  or  the 
peritoneum  widely  opened,  abdominal  section  may  be  expected  to 
give  the  best  results  in  those  cases  in  which  the  condition  of  the 
patient  will  allow  of  such  an  operative  procedure  being  carried  out. 
Only  too  often  the  condition  of  the  patient  is  such  that  no  operative 
interference  of  any  kind  is  possible. 

It  is  exceedingly  difficult,  and  often  indeed  impossible,  to  jDlug  a 
large  tear  in  the  uterine  wall,  perhaps  communicating  widely  with 
the  peritoneal  cavity,  so  firmly  as  to  secure  the  patient  from  the 
risk  of  further  haemorrhage.  This  method  of  treatment,  however, 
has  the  advantage  that  it  can  be  applied  by  any  practitioner  without 
any  assistance  or  special  appliances,  but  it  is  of  little  value  in  cases 
of  extensive  laceration. 

If  the  tear  communicates  freely  with  the  abdominal  cavity,  the 
latter  may  first  be  washed  out  with  sterilised  saline  solution,  by 
means  of  a  Budin's  catheter  passed  through  the  rent,  the  patient 
being  in  the  dorsal  position.  If  any  bleeding  arteries  can  be  seen 
from  the  vagina,  where  the  rent  enters  the  broad  ligament,  they 
should  be  secured  by  pressure  forceps.  The  plug  is  then  placed  so 
that  it  reaches  the  peritoneal  cavity,  and  arrests  haemorrhage  by 
pressure  on  the  sides  of  the  rent,  while  the  end  is  brought  outside 
the  vulva  to  act  as  a  drain.  If  iodoform  or  other  antiseptic  gauze 
is  used,  it  may  be  left  untouched  for  from  forty-eight  to  sixty  hours, 
if  the  patient  is  doing  well,  and  afterwards  renewed  daily.  The 
vagina  may  be  swabbed  out,  when  the  plug  is  changed,  by  solution 
of  formalin  (m  20  ad  Oj.);  but  it  is  better  not  to  use  douches  for 
the  first  five  or  six  days. 

Klien^has  collected  65  cases  treated  by  plugging  with  a  mortality 
of  52  per  cent.,  and  Lobenstine^  records  14  cases  with  a  mortality 
of  02  per  cent. 

1  Klien,  Arclj.  f.  Gyniik.,  liXJl,  lid.  62,  p.  H)8. 

2  Lobenstine,  Bulletin  of  Lying-in  Hospital,  New  York,  VoL  III.,  p.  88. 


944  The  Practice  of   Midwifery. 

In  some  cases,  where  the  rent  involves  chiefly  the  vagina  and 
broad  ligaments,  it  may  be  possible  to  pass  from  the  vagina  deep 
sutures  to  arrest  haemorrhage  by  uniting  the  main  part  of  the  torn 
surfaces,  leaving  a  space  for  drainage  from  Douglas's  pouch. 

If  the  whole  child  has  passed  through  the  opening  into  the 
peritoneal  cavity,  or  even  if  the  head  has  passed  through,  no 
attempt  should  be  made  to  draw  it  back  again  through  the 
opening.  If  this  is  attempted,  the  laceration  and  bruising  are 
likely  to  be  increased.  Moreover,  the  uterus,  being  more  or  less 
emptied,  will  have  retracted.  The  pelvic  space  will  therefore  be 
j)artly  occupied  by  the  double  thickness  of  its  thickened  wall, 
instead  of  merely  that  of  the  attenuated  wall  expanded  over  the 
foetus.  By  this  circumstance  the  difficulty  of  extraction  may  be 
greatly  increased,  if  there  is  any  disproportion  between  foetus  and 
pelvis,  and  therefore  also  the  risk  of  injury. 

In  these  cases  and  in  the  case  of  large  tears,  even  when  the  child 
and  the  placenta  have  remained  in  the  uterine  cavity  and  have  been 
removed  by  the  vagina,  the  best  treatment  is  to  perform  abdominal 
section. 

After  opening  the  abdomen,  removing  the  foetus  and  placenta, 
and  washing  out  all  clots  and  blood  from  the  peritoneal  cavity,  the 
operator  has  the  choice  of  three  methods  of  treating  the  uterus. 
He  may  content  himself  with  packing  the  tear  with  gauze  and 
bringing  the  ends  of  the  gauze  out  through  the  vagina  and  the 
abdominal  wound  for  drainage,  he  may  unite  the  peritoneum  over 
the  tear  or  sew  the  edges  of  the  tear  together,  or  he  may  remove 
the  uterus  by  supra-vaginal  or  total  abdominal  hysterectomy.  All 
these  methods  have  their  advocates,  and  the  choice  between  them 
must  depend  largely  upon  the  circumstances  of  each  individual  case. 
When  the  patient's  condition  is  so  grave  that  it  is  impossible  to 
undertake  either  suture  of  the  laceration  or  removal  of  the  uterus, 
plugging  of  the  tear  may  be  carried  out.  After  cleaning  out  the 
abdominal  cavity,  the  rent  should  be  packed  with  iodoform  gauze, 
one  end  being  brought  out  through  the  vagina  and  the  other 
through  the  lower  angle  of  the  abdominal  wound.  It  is  advisable  to 
pack  the  cavity  of  the  uterus  and  vagina  with  another  strip  of  gauze. 
The  gauze  may  be  renewed  at  about  forty-eight  hours'  interval, 
or  the  first  plug  may  be  left  up  to  three  days,  if  the  patient  is 
doing  well.  Eden^  suggests  that  to  avoid  the  risk  of  sepsis,  if  the 
patient  rallies,  the  uterus  may  be  removed  by  vaginal  hysterectomy 
twenty-four  to  forty-eight  hours  later. 

1  Eden,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  Vol.  XV.,  No.  6,  p.  363. 


Accidents  during  and  after  Labour.         945 

If  the  tear  is  readily  accessible,  the  method  recommended  by  Z  weifel  ^ 
of  uniting  the  peritoneum  over  it  may  be  followed.  He  makes  no 
attempt  to  unite  the  edges  of  the  torn  muscle,  but  this  method  is 
advocated  by  some  operators  and  has  the  advantage  that  the  deep 
sutures,  if  they  can  be  successfully  applied,  arrest  the  haemorrhage. 
In  this  case  the  sutures  should  be  applied,  if  possible,  on  the  same 
principle  as  in  Sanger's  Caesarean  section,  deep  sutures  through  the 
muscular  wall  of  the  uterus,  avoiding  the  mucosa,  or  through  the  cellu- 
lar tissue  if  the  ruj)ture  involves  the  broad  ligament  or  vagina,  and 
suj)erficial  sutures  about  twice  as  numerous  uniting  the  peritoneum, 
and  turning  in  its  edge  either  on  one  side  or  on  both.  The  best 
material  to  use  for  the  sutures  is  sterilised  catgut.  If  the  tear  is 
posterior,  as  it  usually  is,  the  uterus  should  be  turned  out  through 
the  abdominal  wound,  and  the  intestines  held  back  by  large 
sterilised  pads  or  flat  sponges,  so  as  to  allow  access  to  it,  if  possible. 
This  will  be  facilitated  by  the  Trendelenburg  position,  which  may 
be  improvised  with  an  inverted  chair,  as  before  described  (p.  919). 
When  the  anterior  wall  is  involved,  it  is  comparatively  easy  to  apply 
the  sutures.  It  is  most  important  that  free  drainage  either  through 
the  vagina  or  through  the  abdominal  wound  should  be  provided,  since 
the  risk  of  septic  peritonitis  is  very  great,  and  as  the  tissues  are  often 
considerably  bruised,  union  by  first  intention  cannot  be  relied  upon. 
The  chief  objections  to  this  method  of  treatment  are  the  difficulty  of 
carrying  it  out,  the  fact  that  it  is  not  always  successful  in  arresting 
the  haemorrhage,  the  risk  of  rupture  of  the  uterus  in  a  subsequent 
pregnancy,  and  the  great  risk  of  sejDsis. 

A  considerable  number  of  cases  of  repeated  rupture  have  now  been 
recorded,  Varnier  ^  having  collected  15  such  cases,  5  of  which  proved 
fatal.  For  these  reasons  many  operators,  if  the  laceration  is  a  large 
one  or  difficult  to  reach  or  if  it  is  likely  that  the  patient  already  has 
been  infected,  practise  hysterectomy,  either  total  or  supra- vaginal, 
provided  tbat  the  condition  of  the  |)atient  allows  of  such  an  operation 
being  performed.  This  method  of  treatment  has  the  great  advan- 
tages of  securing  certain  arrest  of  the  haemorrhage,  allowing  for 
the  provision  of  free  drainage,  removing  a  possible  source  of  septic 
infection  in  the  uterus,  and  avoiding  the  risk  of  rupture  of  the  uterus 
in  a  subsequent  pregnancy  if  the  patient  recovers.  Unfortunately 
in  the  majority  of  the  cases  the  condition  of  the  patient  is  such  that 
any  such  procedure  is  out  of  the  question.  If  it  is  decided  to  piactise 
it,  the  operation  should  be  performed  in  the  most  rapid  possible 
way.     After  ligature  of  the  ovarian  arteries,  division  of  the  outer 

^  Zvveifel,  Hegur's  Beitrage,  Bel.  7,  p.  1. 

2  Varnier,  Annales  de  Gynecol,  et  d'Obstet.,  October,  I'JOl,  Vul.  LVI.,  p.  2J5. 

M  GO 


946  ^     The  Practice  of   Midwifery. 

part  of  the  broad  ligaments,  and  separation  of  the  bladder,  Doyen's 
clamps  may  be  applied  from  the  vagina  to  the  lower  halves  of  the 
broad  ligaments,  and  left  in  place  forty-eight  hom's,  the  vagina  and 
the  pelvis  being  plugged  with  iodoform  gauze  without  closure  of  the 
peritoneum. 

Kolomenliin  ^  records  among  140  cases  of  rupture  of  the  uterus,  of 
which  97  were  treated  without  operation,  with  a  mortality  of  61  per 
cent.,  33  cases  in  which  the  uterus  was  removed,  with  a  mortality  of 
36*3  per  cent.  Vaginal  hysterectomy  has  the  advantage  over  the 
abdominal  operation  of  being  attended  with  much  less  shock,  and 
may  be  tried  in  these  cases.  In  a  certain  number,  however,  it  will  be 
difficult  to  arrest  the  haemorrhage  completely  by  this  method  ;  and 
as  it  is  only  applicable  to  the  relatively  small  number  of  cases  in 
which  removal  of  the  uterus  is  considered  necessary  when  the 
foetus  and  the  placenta  have  been  retained  in  utcro,  it  has  been  per- 
formed up  to  the  present  time  in  but  a  small  number  of  cases.  On 
the  whole  it  may  be  expected  that  the  treatment  of  these  cases  in  the 
future  will  be  confined  to  plugging  in  the  cases  of  slight  tears  and  of 
abdominal  hysterectomy  when  the  tear  is  at  all  extensive,  and  the 
patient's  condition  admits  of  it.  As  in  most  cases  the  tear  involves 
the  cervix,  total  hysterectomy  will  usually  be  necessary,  but  in  cases 
where  the  cervix  is  not  involved  supra-vaginal  amputation  may  be 
practised. 

Incomplete  Rupture  of  the  Uterus. — There  are  three  varieties 
of  incomplete  rupture  of  the  uterus.  In  the  first,  the  muscular  wall 
is  torn,  while  the  peritoneum  remains  intact ;  in  the  second,  the 
peritoneum  is  torn,  while  the  main  portion  of  the  muscular  wall 
does  not  yield  ;  in  the  third,  the  muscle  tissue  alone  is  torn  without 
involvement  of  the  mucous  membrane.  In  these  cases  there 
may  be  a  good  deal  of  haemorrhage  into  the  muscular  tissue  of 
the  uterine  wall.^ 

Incomplete  rupture  of  the  muscular  wall  takes  place  chiefly  at  the 
sides  of  the  uterus,  where  the  peritoneum  is  not  in  such  close 
contact  with  the  muscle.  It  is  hardly  possible  for  it  to  occur  at  the 
front  or  back  of  the  uterus,  except  at  the  lower  part  of  the  anterior 
wall,  between  uterus  and  bladder.  It  is  much  less  common  than 
complete  rupture.  The  peritoneum  becomes  detached  over  a  con- 
siderable surface,  and  blood  is  poured  out  beneath  it,  forming  a 
hematoma,  especially  when  the  site  of  the  rupture  is  between 
uterus  and  bladder.     In  some  cases  of  complete  rupture  a  similar 

1  Kolornenkin,  Monatsschr.  f.  Geb.  u.  Gyn.,  1903,  Bd.  17,  p.  345. 

2  Kuauer,  Zectralbl.  f.  Gjnak.,  1903,  No.  21,  p.  647. 


Accidents  during  and  after  Labour.  947 

detachment  of  peritoneum  and  effusion  of  blood  are  formed,  showing 
that  an  incomplete  rupture  had  preceded  the  complete.  A  less 
severe  degree  of  internal  rupture,  not  dividing  the  whole  thickness 
of  the  muscular  wall,  may  be  produced  at  the  internal  os  by  efforts 
to  deliver  rapidly,  before  the  internal  os  has  fully  expanded. 

Symptoms. — The  symptoms  of  incomplete  rupture  are  much  less 
marked  than  those  of  complete,  and  the  diagnosis  is  more  difficult. 
The  pains  generally  continue,  although  they  may  become  less 
efficient.  The  chief  symptoms  are  acceleration  of  pulse  and 
haemorrhage.  Little  or  no  blood,  however,  may  escape  externally, 
if  the  presenting  part  prevents  its  exit.  A  sign  which  has  been 
observed  in  some  cases  is  that  of  emphysema  of  the  anterior  wall  of 
the  uterus,  or  extending  to  the  iliac  fossa,  and  even  to  more  distant 
parts.  The  air  may  find  entry  from  the  vagina,  or  there  may  be 
gas  arising  from  decomposition  of  the  foetus,  or  the  bacillus  capsu- 
latus  aerogenes  may  have  infected  the  cellular  tissue.  Cases  in 
which  emphysema  has  been  noted  have  generally  ended  fatally. 

Prognosis. — Although  the  accident  appears  much  less  severe  than 
that  in  which  the  peritoneal  cavity  has  been  opened,  the  mortality 
of  recorded  cases  has  been  high.  Death  has  often  occurred  from 
septic  peritonitis,  or  cellulitis  spreading  from  the  vicinity  of  the 
blood-clot. 

Treatment. — If  the  accident  is  suspected,  delivery  should  be 
effected  rapidly,  as  in  the  case  of  complete  rupture.  Haemorrhage 
can  generally  be  arrested  by  securing  contraction  of  the  uterus,  after 
removal  of  the  placenta,  and  packing  any  lacerated  cavity  in  the 
broad  ligament  with  iodoform  gauze.  The  after-treatment  consists 
chiefly  in  preserving  the  discharge  from  decomposition,  by  frequent 
syringing  with  antiseptic  solutions  and  use  of  iodoform  pessaries. 

If  the  abdomen  has  been  opened  under  the  impression  that  the 
tear  is  a  complete  one,  it  should  be  closed  and  the  laceration  plugged 
and  drained  from  the  vagina.  The  best  plug  to  use  in  these  cases 
is  antiseptic  gauze  enclosing  a  large  drainage  tube. 

The  second  variety  of  incomplete  rupture  has  been  described  in  a 
few  cases  in  which  death  has  occurred  from  haemorrhage  or  shock, 
or  from  subsequent  peritonitis.  Cases  not  ending  fatally  would 
probably  escape  recognition. 

Perforation  of  the  Uterus.  —  Localised  inflammation  and 
sloughing  of  the  uterine  wall  may  be  produced  by  prolonged 
pressure  between  some  projecting  part  of  the  pelvis  and  the  pre- 
senting part  of  the  fcttus,  especially  when  the  head  is  presenting. 

60—2 


948  •     The  Practice  of   Midwifery. 

The  bony  prominence  most  likely  to  cause  this  effect  is  the  pro- 
montory of  the  sacrum  in  a  flattened  pelvis.  In  protracted  labour, 
especially  when  the  head  is  arrested  above  the  brim,  the  internal 
OS  may  be  so  much  elevated  by  retraction  of  the  uterus,  that  the 
sacral  promontory  corresponds  to  a  portion  of  the  cervix,  or,  at  any 
rate,  of  the  thinned  lower  segment  of  the  uterus.  In  the  more 
rare  case  in  which  there  are  projecting  spines  or  bony  prominences 
at  other  parts  of  the  pelvis,  as  at  the  symphysis  pubis,  these  also 
may  cause  a  similar  local  lesion  in  the  uterus.  Sloughing,  especially 
at  the  site  of  the  sacral  promontory,  is  most  commonly  due  to 
prolonged  pressure,  when  labour  has  been  left  too  long  unassisted. 
It  may  also  result  from  injury  in  very  difiicult  instrumental  delivery, 
or  from  the  use  of  unsuitable  instruments,  or  the  unskilful  use  of 
instruments. 

The  portion  of  the  uterine  wall  which  sloughs  may  give  way  and 
form  a  rounded  or  funnel-shaped  perforation  into  the  peritoneal 
cavity ;  or  its  inner  or  outer  portion  loany  alone  give  way,  not  pro- 
ducing a  complete  perforation.  In  sloughs  on  the  anterior  wall, 
the  peritoneal  cavity  is  not  usually  reached,  but  only  the  cellular 
tissue  in  front  of  the  uterus.  As  in  the  case  of  sloughs  causing 
vesico -vaginal  fistula,  the  perforation  generally  does  not  take  place 
before,  or  at  the  time  of,  delivery,  but  after  an  interval  of  some 
days.  It  is  not  so  fatal  as  rupture  of  the  uterus,  because  peritoneal 
adhesions  may  have  meantime  formed  around  it.  It  may,  however, 
set  up  general  peritonitis,  and  is  one  of  the  causes  of  death  after 
difficult  labour. 

Lacerations  of  the  Vaginal  Portion  of  the  Cervix. — Slight 
superficial  lacerations  of  the  mucous  membrane  at  the  edge  of  the  os 
are  almost  inevitable  in  labour.  Deeper  lacerations  are  of  common 
occurrence.  These  may  extend  either  partially  or  wholly  up  to  the 
vaginal  reflection,  or  may  even  reach  the  adjoining  portion  of  the 
vagina  and  subjacent  cellular  tissue.  It  is  very  rare  for  lacerations 
commencing  at  the  edge  of  the  cervix  to  extend  up  to  the  internal 
OS,  but  rents  caused  by  forcible  delivery  with  an  undilated  cervix 
may  possibly  do  so.  They  then  virtually  become  incomplete  or 
complete  ruptures  of  the  uterus,  as  the  case  may  be. 

Transverse  lacerations,  j)arallel  to  the  edge  of  the  os,  are  much 
more  rare.  Such  a  laceration  may  be  produced  by  pressure  of  the 
advancing  head,  when  there  is  deviation  of  the  os  uteri  to  one  side ; 
or  the  anterior  lip,  compressed  between  the  occiput  and  the  pubes, 
may  become  injured  and  inflamed,  and  may  give  way  in  the  form 
of  a  transverse  laceration.    Cases  have  even  been  recorded  in  which, 


Accidents  during  and  after  Labour,         949 

when  the  os  is  very  rigid,  such  a  laceration  has  extended  all  the  way 
round,  and  separated  the  edge  of  the  cervix  in  the  form  of  a  ring. 
This  constitutes  an  annular  laceration. 

Causation. — Laceration  results  from  rigidity  of  the  cervix,  com- 
bined either  with  activity  of  the  expelling  forces,  or  artificial  extrac- 
tion. The  rigidity  may  either  be  due  to  a  previous  inflammation  or 
hyperplasia  of  the  cervix,  or  to  labour  occurring  for  the  first  time 
late  in  life.  Premature  rapture  of  the  meml)ranes  greatly  predis- 
poses to  laceration,  through  the  failure  of  the  natural  mechanism 
for  gradual  dilatation.  The  lacerating  force  may  be  the  natural 
expulsive  power,  or  that  expended  in  delivery  by  forceps,  or  traction 
in  pelvic  presentations  or  after  version. 

Symptoms  and  Results. — There  is  generally  no  symptom 
which  attracts  notice  at  the  time  of  the  laceration,  the  pain  pro- 
duced being  merged  in  the  pain  of  uterine  contraction.  Until 
delivery  hsemorrhage  is  generally  checked  by  the  presence  of  the 
foetus.  After  delivery,  haemorrhage  may  occur,  and  form  one  of 
the  varieties  of  jwst-partuni  hemorrhage.  It  is  only  in  excep- 
tional cases,  however,  that  it  is  sufficient  to  call  for  any  special 
treatment. 

The  slighter  lacerations  generally  heal  more  or  less  completely 
during  the  puerperal  period,  but  often  leave  the  cervix  irregular, 
and  marked  by  notches  radiating  from  the  cervix.  A  deep  lacera- 
tion reaching  the  vaginal  reflection  is  apt  to  cause  local  cellulitis  in 
its  neighbourhood,  owing  to  absorption  at  the  raw  surface.  This 
is  proved  by  the  frequency  with  which,  when  an  old  ununited 
laceration  is  discovered  long  after  the  labour  which  gave  rise  to  it, 
a  band  of  thickening  in  the  cellular  tissue  running  from  the  angle 
of  the  laceration  can  also  be  detected.  Septic  absorption  of  a 
more  grave  character  at  the  same  site  may  give  rise  to  puerperal 
septicgemia.  When  laceration  is  deep,  and  especially  when  the 
cervix  is  lacerated  at  both  sides,  the  clefts  are  apt  to  remain 
unhealed,  and  the  anterior  and  posterior  lips  of  the  cervix  to 
become  everted  and  hyperfcrophied.  The  lining  membrane  of  the 
cervix,  naturally  clothed  with  cylindrical  epithelium,  is  thus  exposed 
to  friction,  and  to  the  action  of  the  vaginal  secretion.  The  result 
commonly  is  a  chronic  hypersemia  and  hypertrophy  of  the  exposed 
mucous  membrane.  The  effect  of  unhealed  laceration  of  the  cervix 
may  thus  be  chronic  uterine  trouble,  lasting  for  many  years. 

Diagnosis. — ^The  laceration  may  sometimes  be  noticed  at  the 
time  of  its  occurrence,  or  suspected  from  the  sudden  yielding  of  a 


950  The  Practice  of   Midwifery. 

long-resisting  cervix.  In  all  cases,  when  the  placenta  is  removed, 
if  there  is  any  occasion  for  introducing  the  finger  into  the  vagina, 
the  physician  should  examine  the  cervix,  which  hangs  limp  and 
flaccid,  to  determine  whether  there  are  any  rents  in  it,  and  their 
degree. 

Prophylaxis. — The  most  important  point  in  prophylaxis  is  to 
avoid  increasing  the  number  of  lacerations  which  would  occur  spon- 
taneously by  using  forceps  unnecessarily  before  full  retraction  of  the 
OS,  or  by  extracting  too  hastily  in  those  cases  in  which  forceps  are 
called  for.  When  laceration  is  threatened  by  rigidity  of  the  os  in 
association  with  violent  pains,  all  means  should  be  used  to  promote 
relaxation,  such  as  hot  water  irrigation,  and,  above  all,  the  adminis- 
tration of  chloroform.  After  premature  rupture  of  the  membranes, 
if  the  OS  does  not  readily  yield,  laceration  may  sometimes  be  averted 
by  the  judicious  use  of  dilating  bags  or  dilatation  with  the  fingers 
(see  pp.  638—640). 

Treatment. — Haemorrhage  may  be  checked  by  hot  douches,  or,  if 
necessar}^  by  plugging  with  gauze.  A  still  better  and  more  scientific 
plan  is  to  arrest  the  hfemorrhage  by  uniting  the  laceration  by 
sutures.  For  this  purpose,  the  patient  should  be  placed  in  Sims' 
semi-prone  position,  lying  on  the  side  opposite  to  the  laceration. 
Sims'  speculum  should  be  used,  or  the  cervix  drawn  down  to  the 
vulva  by  tenaculum  forceps.  The  best  material  for  sutures  is  stout 
silkworm  gut.  Two  sutures  are  generally  sufficient  for  one  side  of 
the  cervix,  and  these  may  be  apj^lied  with  a  straight  needle  held  in 
a  needle-holder,  or,  still  better,  by  Hagedorn's  needle-holder 
(Fig.  471,  p.  955)  and  curved  needles.  They  should  be  removed 
at  the  end  of  a  week.  The  sutures  should  be  passed  through  the 
whole  thickness  of  the  cervix,  just  including  the  edge  of  the  lining 
cervical  mucous  membrane.  It  is  not  usual  to  perform  an  imme- 
diate operation  on  the  laceration  in  those  cases  in  which  there  is 
no  bleeding  of  consequence.  For  it  appears  that,  in  general,  if 
careful  vaginal  irrigation  is  employed,  and  all  sepsis  avoided,  fair 
healing  of  the  lacerations  takes  place  spontaneously. 

If  a  laceration  has  been  detected  after  labour,  it  is  desirable  to 
examine  the  condition  of  the  cervix  some  weeks  after  delivery,  in 
order  to  decide  whether  the  operation  of  trachelorraphy  is  called  for, 
or  whether  any  other  treatment  is  necessary. 

Laceeations  of  the  Vagina. — Lacerations  of  the  posterior  vaginal 
cul-de-sac  reaching  the  peritoneum,  and  vaginal  associated  with 
cervical  lacerations,  have  already  been  described.     In  the  middle 


Accidents  during  and  after  Labour.         951 

portion  of  a  normal  vagina,  spontaneous  laceration  rarely  occurs, 
since  the  canal  is  capable  of  stretching  to  the  dimensions  of  the 
pelvis.  If,  however,  the  vagina  is  contracted  by  old  cicatrices, 
laceration  may  take  place,  and  may  reach  even  the  bladder  or  the 
rectum.  Vaginal  lacerations  may  also  be  produced  by  unskilful  use 
of  instruments,  or  by  projecting  angles  of  bone  in  craniotomy. 


Fig.  467. — Incomplete  rupture  of 
perineum.     (Bumm.) 


Fig.  468.— Complete  rupture  of  perineum 
into  rectum.     (Bumm.) 


Treatment. — Sutures  will  rarely  be  required,  unless  the  bladder 
or  rectum  is  laid  open,  or  for  the  arrest  of  haemorrhage.  Care 
should  be  taken  afterwards  to  guard  against  decomposition  of  lochia 
in  the  vagina. 

Lacerations  of  the  Vaginal  Outlet,  Vulva,  and  Perineum. — 
The  vaginal  outlet,  formed  by  the  insertion  of  the  hymen,  is  the 
narrowest  point  of  the  canal,  and  suffers  inevitable  rupture  in 
primipane.    In  coitus  only  the  edge  of  the  hymen  becomes  notched, 


952 


The  Practice  of  Midwifery. 


PevTTVfum      \ 


the  notches  not  reaching  quite  to  its  base.  In  parturition  lacera- 
tions extend  quite  to  its  base,  and  reach  the  ceUular  tissue  of  the 
vaginal  wall.  These  lacerations  are  longitudinal,  being  perpen- 
dicular to  the  direction  of  greatest  tension.  The  main  tear  is 
in  most  cases  posterior,  but  there  are  usually  others  also.     Hence, 

the  condition  of  the  hymen 
generally  affords  positive 
evidence  as  to  previous  par- 
turition. 

Laceration  of  the  perineum 
in  primiparse  generally  com- 
mences by  extension  into  the 
substance  of  the  perineal 
body  from  the  inevitable 
tear  at  the  vaginal  outlet, 
which  is  shown  by  the  line  e  c 
in  Fig.  469.  The  term 
perineal  body  is  applied  to 
the  lower  part  of  the  recto- 
vaginal septum.  A  longitu- 
dinal section  of  this  forms 
(roughly)  a  triangle  (a  h  c, 
Fig,  469),  the  base  of  which 
{h  c)  is  constituted  by  the 
perineum  proper.  Up  to  the 
jBrst  parturition,  the  remnant 
of  the  hymen  at  the  vaginal 
outlet  (d,  Fig,  469)  forms  a 
projection  forward  near  the 
lower  extremity  of  the  anterior 
or  vaginal  face  of  the  triangle. 
A  considerable  laceration  of 
the  vaginal  face  of  the 
triangle,  occurring  by  exten- 
sion upwards  and  inwards  of 
the  inevitable  tear,  e  c,  may 
take  place  without  the  perineum  itself,  or  even  the  fourchette,  or 
fold  of  slvin  uniting  its  anterior  border,  being  involved  at  all.  This 
may  divide  so  much  of  the  anterior  fibres  of  the  levator  ani  (see 
Fig.  143,  p,  237),  that  the  action  of  that  muscle  in  coitus,  and  the 
value  of  the  perineal  body  as  a  support  for  the  vagina,  are  impaired 
thenceforward,  the  perineum  being  left  only  as  a  thin  septum,  like 
an    artificial  perineum  produced  by  a  badly-performed    operation. 


\ 


Fig.  469. — Antero-posteriia*  section  of  peri- 
neal body  in  pvimiparfe.  a,  recto- 
vaginal septum  ;  //  c,  perineum  ;  c,  four- 
chette ;  d,  vaginal  outlet,  formed  by 
remnant  of  hymen  ;  c  d.  fossa  navicularis  ; 
e  c,  inevitable  laceration  in  primipara?  ; 
/  e,  deeper  laceration  of  vaginal  surface 
of  perineal  body  not  involving  perineum 
itself ;  f  cj,  laceration  of  perineum  up  to 
sphincter  ani  ;  f  h,  f  h,  lacerations 
dividing  sphincter  ani  ;  1  ]',  2  2',  show 
position  of  sutures  for  uniting  the 
laceration.  The  section  shows  the  shape 
of  the  perineal  body  when  slightly 
stretched  transversely,  as  by  the  advanc- 
ing head.  In  its  unstretched  condition 
the  fourchette  [c)  lies  posterior  to  the 
vaginal  outlet  {d). 


Accidents  during  and  after  Labour.         953 

In  rare  cases,  superficial  cutaneous  cracks  of  the  perineum  are 
alone  produced,  the  skin  being  less  distensible  than  the  muscle 
beneath,  which  remains  intact. 

Deep  Lacerations. — More  frequently,  as  the  laceration  spreads,  it 
involves  the  perineum  proper  and  extends  more  or  less  from  the 
fourchette  backward  toward  the  anus.  Sometimes  only  just  the 
anterior  margin  is  torn  through,  and  women  who  have  had  several 
children  rarely  escape  so  much  laceration  as  this.  In  a  more 
severe  form  of  rupture  the  laceration  extends  backward  as  far  as 
the  sphincter  ani,  as  shown  by  the  \mefg  in  Fig.  469.  Sometimes 
the  tear  forks  on  reaching  the  sphincter,  going  a  little  to  each  side 
without  dividing  the  muscle.  In  others  the  skin  only  may  be 
divided  as  far  as  the  anus,  while  the  muscle  beneath  remains  intact. 
In  the  severest  form  of  all,  the  sphincter  ani  is  divided,  and  more 
or  less  of  the  recto-vaginal  septum,  as  shown  by  the  lines  fh,fk, 
in  Fig.  469.  The  line  of  rent  in  the  recto-vaginal  septum  generally 
deviates  somewhat  to  one  side,  avoiding  the  central  posterior 
column  of  the  vagina,  where  the  tissue  is  thicker  and  stronger.  In 
parous  women,  in  whom  the  inevitable  laceration  at  the  vaginal 
outlet  must  have  taken  place  at  a  former  delivery,  rupture  generally 
commences  at  the  anterior  margin  of  the  perineum,  and  extends 
backward  from  that  point. 

Central  Rupture.- — ^In  rare  cases,  when  the  vulval  outlet  is  very 
narrow  and  far  forward,  and  when  the  head  is  driven  backward, 
what  is  called  central  rupture  of  the  perineum  occurs,  laceration 
taking  place  from  the  vagina  through  to  the  perineum,  leaving  the 
anterior  portion  of  the  perineum  intact  in  front.  Cases  have  been 
recorded  in  which  the  rent  has  extended  backward  through  the 
sphincter  into  the  rectum,  and  the  child  has  been  born  through  the 
opening,  a  bridge  of  perineum  in  front  still  remaining  unruptured. 

Causation  and  Prophylaxis.— The  stage  of  delivery  at  which 
laceration  is  liable  to  occur,  and  the  precautions  to  be  taken  for 
avoiding  it,  have  been  described  in  the  chapter  on  the  management 
of  normal  labour  (see  pp.  302 — 304).  It  may  be  added  here  that 
laceration  may  sometimes  be  produced  before  the  foetus  reaches  the 
pelvic  floor,  when  the  hand  and  arm,  or  instruments,  have  to  be 
introduced,  especially  in  difficult  cases  of  craniotomy.  For  the 
precautions  to  be  used  to  avoid  lacerating  the  perineum  in  forceps 
delivery,  see  p.  852. 

Diagnosis.— If  a  careful  watch  is  kept  upon  the  perineum  when- 
ever rupture  is  threatened,  any  laceration  will  be  noted  at  the  time 


954  The  Practice  of   Midwifery. 

of  its  occurrence.  Visual  examination  is  better  than  digital,  and 
can  be  made  at  the  time  when  the  placenta  and  membranes  are 
removed  from  the  vagina.  Care  should  be  taken  to  have  a  sufficient 
light,  if  there  is  any  doubt  about  the  perineum  being  perfectly 
intact.  Some  practitioners  have  been  known  to  say  that  they 
never  see  rupture  of  the  perineum  in  their  practice;  This  state- 
ment proves  only  that  they  are  not  accustomed  to  examine  their 
patients  after  delivery  with  sufficient  care. 

Symptoms  and  Results.— There  are  generally  no  notable 
symptoms  at  the  time  of  laceration,  the  pain  being  merged  in  the 
distress  of  the  final  pains  of  labour.  Haemorrhage  is  usually  not 
considerable,  unless  the  rupture  extends  far  up  the  recto-vaginal 
septum.  After  delivery,  there  is  soreness  at  the  site  of  laceration. 
If  the  laceration  is  not  united  b}^  sutures,  a  certain  amount  of 
spontaneous  union  may  take  place.  Generally,  however,  if  the 
laceration  is  deep,  there  is  but  little  union  of  the  separated  surfaces, 
and  such  apparent  diminution  of  the  size  of  the  rent  as  takes  place 
is  due  to  some  contraction  of  the  healing  surface,  and  filling  up  of 
the  angle  by  granulation.  During  the  puerperal  period,  the  raw 
surface  affords  a  site  for  the  absorption  of  any  septic  material 
which  may  be  present,  and  may  thus  form  the  starting-point  for 
puerperal  septicaemia.  If  septic  infection  has  taken  place,  this 
surface  may  become  sloughy,  or  may  be  covered  by  a  greyish 
exudation.  If  a  considerable  laceration  has  occurred  and  is  not 
united,  the  following  are  the  subsequent  results.  The  support 
given  by  the  perineal  body  to  the  anterior  vaginal  wall  is  taken 
away.  Hence  there  is  liability  to  prolapse  of  the  anterior  vaginal 
wall,  which  may  in  turn  draw  down  the  uterus.  The  gaping 
vaginal  outlet  may  also  allow  prolapse  of  the  posterior  vaginal 
wall,  mdependently  of  the  uterus.  The  sexual  power  of  the  woman 
is  also  impaired  in  consequence  of  the  division  of  the  sphincter 
vaginse  and  anterior  fibres  of  the  levator  ani. 

Treatment. — In  all  cases  in  which  rupture  has  occurred  beyond 
the  extent  of  a  mere  notch  in  the  mucous  membrane  or  at  the 
fourchette,  it  should  be  closed  immediately  by  sutures.  The 
object  of  this  treatment  is  not  only  to  avert  the  subsequent  evils 
arising  from  an  ununited  laceration,  but  to  diminish  the  absorbent 
surface  capable  of  proving  the  starting-point  of  septicaemia.  If 
there  is  merely  a  slight  rent  affecting  the  vaginal  mucous  mem- 
brane only,  and  not  reaching  the  perineum  proper,  sutures  are  not 
generally  required. 


Accidents  during  and  after  Labour.  955 

If,  however,  there  is  a  deep  rent  in  this  situation,  as  shown  by 
the  line /c  in  Fig.  469,  p.  952,  so  that  only  a  thin  surface  of 
perineum  is  left,  the  vaginal  mucous  membrane  may  be  united  by 
one  or  two  sutures. 

Lacerations  not  dividirig  the  Sphincter  Ani. — A  laceration  not 
dividing  the  sphincter  ani  may  be  closed  by  sutures  almost  imme- 
diately after  delivery.  The  use 
of  an  anaesthetic  is  not  essential, 
if  the  patient  is  tolerant  of  pain. 
But  an  anaesthetic  may  be  given, 
if  there  has  been  no  excessive 
haemorrhage,  if  the  uterus  is 
well  contracted,  and  about  an 
hour  has  elapsed  since  the 
delivery  of  the  foetus,  the 
placenta  having  been  also 
delivered.  A  pad  of  sterilised 
or  antiseptic  wool  may  be  placed  in  the  vagina  to  dam  back  the 
sanguineous  discharge,  while  the  stitches  are  being  passed.  The 
best  material  for  sutures  is  silkworm  gut.  But  it  is  better  to 
use  ordinary  sewing  silk  than  to  leave  the  laceration  ununited. 
The  sutures  can  be  applied  still  more  conveniently  by  means  of 
Hagedorn's   needle-holder   and   curved    needles    (Figs.   470,    471, 


Fig.  470. — Hagedorn's  needles. 


Fig.  471.— Hagedorn's  needle-holder. 


the  needles  being  flattened  at  the  sides.  The  needles  being 
larger,  give  somewhat  more  pain,  but,  if  an  anaesthetic  is  used, 
they  have  a  distinct  advantage.  The  circular  curved  needles 
should  be  chosen,  or  an  ordinary  curved  handled  perineum  needle 
may  be  employed.  The  stitches  may  often  be  inserted  without 
moving  the  patient  from  the  lateral  position  in  which  she  is  lying. 
But  the  operation  is  easier  if  she  is  placed  on  her  back,  the  trunk 
transverse    to  the  bed,  and  if  her  feet  are  rested  on  a  couple  of 


956  The  Practice  of   Midwifery. 

chairs,  the  operator  standing  between  them.  The  labia  may  then 
be  separated  somewhat  by  the  nm'se.  The  needle  should  be 
passed  through  the  whole  thickness  of  the  perineum,  entering 
about  a  quarter  of  an  inch  from  the  edge  on  the  cutaneous 
surface,  and  emerging  as  nearly  as  possible  on  the -edge  of  the 
vaginal  mucous  membrane,  the  central  part  of  its  course  being 
the  deepest.  On  the  patient's  left  side  the  needle  is  passed  from 
without  inward,  and  on  the  right  side  from  within  outward,  and 
the  loop  of  suture  is  thus  completed.  In  general  two  sutures  are 
sufficient.  The  mode  in  which  tbey  raaj  be  applied  for  a  laceration 
extending  up  to  the  sphincter  is  shown  at  1  1',  2  2',  in  Fig.  469, 
p.  952.  An  error  specially  to  be  avoided  is  to  unite  the  perineum 
too  suj)erficially,  not  carrying  the  needles  through  to  the  vaginal 
mucous  membrane.  A  thin  perineum,  useless  as  a  vaginal  support, 
is  then  likely  to  result. 

If  the  application  of  sutures  has  been  neglected  at  the  time  of 
delivery,  it  is  desirable  to  apply  them  later,  even  up  to  a  week  after 
delivery,  especially  if  any  pyrexia  has  occurred.  If  granulations 
have  formed,  the  granulating  surface  should  be  scraped  by  a  curette 
or  sharp  spoon. 

If  sutures  are  thought  desirable  in  any  case  of  laceration  affecting 
onl}^  the  vaginal  side  of  the  perineal  body,  as  along  the  line  /  c  in 
Fig.  469,  and  not  reaching  the  perineum  proper,  one  or  two  may 
be  applied  within  the  vagina  by  means  of  a  curved  needle,  held  in 
a  needle-holder.  Hagedorn's  needle-holder  and  needles  are  the  best 
in  this  case  also. 

Vaginal  douches  need  not  be  used.  The  patient  may  be  allowed 
to  pass  her  urine  as  usual,  but  the  external  genitals  should  be  well 
douched  and  washed,  immediately  after  she  has  done  so.  After  the 
first  day  or  two,  she  may  pass  urine  raised  in  the  sitting  position  on 
the  bedpan.     The  sutures  should  be  removed  in  about  a  week. 

Lacerations  dividing  the  Sphincter  Ani. — When  the  sphincter  ani 
is  divided,  the  sutures  should  be  applied  in  the  same  way  as  in  the 
gynsecological  operation  for  ruptured  perineum.^  Sufficient  time 
after  delivery  should  be  allowed  to  elapse  to  obviate  the  risk  of 
haemorrhage,  say  at  least  an  hour,  and  a  full  dose  of  ergot  should  be 
given.  An  anaesthetic  should  be  given,  and  there  should  be  an 
assistant  to  administer  it.  Ether  should  be  chosen  rather  than 
chloroform,  that  the  relaxing  effect  uj)on  the  uterus  may  be  less, 

A  sufficient  number  of  stitches  of  chromic  catgut  may  be  used 
to   unite  the  rectal  mucous  membrane,  the  knots  being  tied  or 

1  For  full  description  and  figure  of  the  operation,  see  Galabin's  Diseases  of 
Women. 


Accidents  during  and  after  Labour.  957 

twisted  on  the  rectal  side.  Then,  by  means  of  a  Hagedorn's  needle, 
one  suture  is  passed  completely  round  from  side  to  side,  through 
the  remains  of  the  septum,  being  buried  throughout  its  course, 
the  ends  being  close  to  the  anus  at  each  side.  Four  or  more 
perineal  sutures  of  silkworm  gut  are  then  applied.  Care  must 
be  taken  that  the  posterior  suture  takes  up  the  ends  of  the 
sphincter  ani.  It  may  be  buried  throughout  its  course,  and 
completely  encircle  the  rent,  if  the  rent  is  not  too  deep. 

If  the  rent  extends  far  up  the  septum,  a  third  set  of  sutures 
should  be  used  to  unite  the  vaginal  mucous  membrane  at  the 
upper  part  of  the  rent.  The  knots  of  these  are  tied  in  the  vagina, 
and  the  sutures  may  be  of  silkworm  gut  or  chromic  catgut.  If  the 
former  is  used,  the  sutures  should  not  be  removed  till  several  days 
after  the  removal  of  the  perineal  sutures.  Chromic  catgut  sutures 
are  left  to  dissolve. 

In  a  rupture  dividing  the  sphincter,  it  is  well  to  keep  the  bowels 
confined  for  three  days,  and  to  give  a  little  opium  for  this  purpose, 
in  order  to  allow  time  for  primary  union.  It  is  a  mistake,  however, 
to  keep  the  bowels  locked  up  for  a  week  or  ten  days,  for  the  collec- 
tion of  hard  faeces  is  then  apt  to  break  down  the  union.  At  the 
end  of  three  days  the  bowels  may  be  opened  by  a  full  dose  of  castor 
oil,  and  it  is  a  good  plan  to  administer  an  oil  enema  of  8  oz.  of 
olive  oil  just  before  they  are  moved.  From  this  time  the  bowels 
should  be  kept  acting  daily  by  a  very  gentle  laxative.  Until  the 
bowels  have  acted,  the  diet  should  be  sparing,  and  consist  mainly 
of  milk.  The  catheter  need  not  be  used  unless  the  patient  is 
unable  to  pass  water  naturally.  After  each  action  of  the  bowels  or 
act  of  micturition  the  perineum  should  be  carefully  cleansed  by 
means  of  a  syringe,  and  may  be  dusted  over  with  iodoform  or  boric 
acid  powder.  The  perineal  sutures  should  be  removed  in  about 
seven  days.  It  is  well  at  first  to  take  out  alternate  sutures  only, 
and  to  leave  the  long  suture  encircling  the  septum,  and  one  or  two 
others,  for  two  days  longer. 

Laceration  of  the  Vulva. — Lacerations  may  take  place,  not 
only  at  the  posterior  surface  but  at  the  sides  of  the  vulva  or  near 
the  clitoris.  They  are  generally  parallel  to  the  axis  of  the 
vagina,  that  direction  being  perpendicular  to  the  line  of  greatest 
tension.  Some  haemorrhage  after  delivery  may  arise  from  such 
lacerations,  especially  if  the  plexus  of  veins  at  the  side  of  the 
vestibule  is  torn. 

Treatment. — Hemorrhage  may  be  arrested  by  bringing  together 
the  edges  of  the  laceration  with  one  or  two  sutures. 


958        '       The  Practice  of   Midwifery. 

EuPTURE  OF  THE  Pelvic  ARTICULATIONS.^ — The  relaxation  of 
the  pelvic  articulations  which  occurs  in  pregnancy  in  very  varying 
degree  has  already  been  described.  Actual  sej)aration  at  the  joints 
sometimes  occurs  in  labour.  When  preceded  by  excessive  relaxa- 
tion of  the  joints  before  delivery,  this  sometimes  happens  under  the 
influence  of  the  natural  expulsive  forces  only.  More  frequently  it 
is  produced  by  efforts  at  artificial  extraction,  especially  in  the  high 
forceps  operation.  The  joint  may  then  sometimes  give  way  with 
an  audible  crack. 

The  joint  most  frequently  ruptured  is  the  symphysis  pubis. 
The  separation  may  take  place  at  the  symphysis  itself,  or  the 
cartilage  may  be  broken  away  from  one  pubic  bone.  For  any 
space  in  the  pelvis  to  be  gained  by  the  rupture,  it  is  inevitable 
that  some  separation  should  take  place  also  at  another  of  the  pelvic 
joints.  Accordingly,  with  rupture  at  the  symphysis  pubis  there 
is  commonly  combined  some  separation  at  one  or  both  sacro-iliac 
joints,  but  the  experience  of  symphysiotomy  shows  that  this  is 
not  usually  of  serious  consequence.  Usually  the  anterior  part  of 
the  joint  alone  is  separated,  the  posterior  remaining  intact.  With 
the  rupture  of  the  symphysis  pubis  may  be  associated  laceration 
of  the  anterior  wall  of  the  bladder,  the  anterior  vaginal  wall,  or 
the  urethra. 

The  accident  occurs  most  frequently  when  there  is  lack  of 
transverse  space,  as  in  the  uniformly  contracted  pelvis.  The  effect 
of  traction  is  then  to  draw  the  pubic  bones  directly  apart.  In  the 
flattened  pelvis  this  is  not  the  case. 

Diagnosis. — There  is  pain  and  tenderness  in  the  situation  of 
the  affected  joints,  and  inability  to  move  the  legs.  Pain  in  the 
joints  is  produced  by  pressure  on  the  innominate  bone.  On 
bimanual  examination  the  mobility  of  one  pubic  bone  on  the 
other  may  be  detected.  According  to  Ahlfeld  the  thighs  are 
everted. 

Prognosis. — In  the  majority  of  cases  the  result  has  been 
favourable,  unless  septic  infection  has  resulted  in  consequence 
of  other  lesions  due  to  the  difficulty  of  labour.  Generally  the 
joints  have  become  consolidated  again.  In  some  cases,  when  the 
joints  have  not  been  kept  at  rest,  abscesses  have  formed  at  the 
site  of  rupture. 

^  See   Ahlfeld,    Die   Verletzungen   der   Beckengelenke,    etc.,    Schmidt's   Jahibuch, 
1876,  Bd.  169,  p.  185. 


Accidents  during  and  after  Labour.         959 

Treatment.— A  firm,  strong  binder,  should  be  placed  round 
the  pelvis,  and  the  patient  should  be  kept  at  rest  in  bed  longer 
than  the  usual  period,  until  the  tenderness  in  the  joints  has 
subsided.  She  should  still  wear  a  binder  round  the  pelvis,  when 
beginning  to  get  about,  until  freedom  of  locomotion  is  restored 

If  undue  mobility  of  the  bones,  producing  lameness,  persists,  it 
may  be  necessary  to  expose  the  joint  by  incision,  and  bring  together 
by  sutures  the  fibrous  tissue  close  to  the  bones,  or  even  to  wire 
together  the  pubic  bones. 

Obstetrical  PARALYsis.-The  nerves  of  the  sacral  plexus  may 
suffer  injury  from  pressure,  especially  in  cases  of  general  contrac- 
tion of  pelvis  with  a  large  head,  either  from  spontaneous  delivery 
or  the  high  forceps  operation.     Generally  one  leg  only  is  affected 
accordmg  to  the  diagonal  diameter  of  the  pelvis  in  which  the  long 
diameter  of  the  foetal  head  lies.     The  external  popliteal  nerve  is 
most  often  affected,  in  consequence  of  pressure  upon  the  fourth 
and  fifth    umbar  roots  which  supply  it  as  they  pass  over  the  brim 
ot  the  pelvis.      According  to  Schwenkenbecher,i  in  34  recorded 
cases,  complete  recovery  followed  in  only  4,  partial  recovery  in  15 
no  recovery  in  15.     Occasionally  some  of  the  other  nerves  of  the 
sacral  plexus,  such  as  the  sciatic,  are  affected  either  by  neuritis  or 
from   involvement   in   an   inflammatory  exudation   in  the  pelvis 
Paralysis  of  one  or  more  nerves   (or  rarely  of   a   large  number) 
from  peripheral  neuritis  has  also  occurred  in  the  puerperal  period 
and  has  been  ascribed  to  the  action  of  a  toxin 

Cerebral  hemorrhage  leading  to  death  or  hemiplegia  sometimes 
occurs  near  the  time  of  delivery,  and  is  promoted  by  the  changes  of 
vascular  pressure  caused  by  the  efforts  of  labour. 

Treatment.-In  local  paralysis  early  recourse  should  be  had  to 
electrical  treatment. 

HEMATOMA  OF  THE  BROAD  LIGAMENT  has  Occasionally  followed 
version  or  other  operative  interference.  It  has  been  known  to 
rupture  into  the  peritoneal  cavity,  with  a  fatal  result  (see  p.  661). 

Presentation,  Prolapse,  and  Expression  of  the  Funis. 

The   funis_  is    said    to    present   when,    before    rupture    of  the 

membranes,  it  is  felt  in  front  of,  or  in  conjunction  with,  any  other 

preseiitmg  part.     In  such  circumstances,  as  soon  as  the  membranes 

rupture,  a  loop  of  the  funis  generally  descends  through  the  os,  or 

'   JJoulsoh.  Arch.  f.  Klin.  Med.,  ]1)02,  Bd.  74,  ,,.  .r,03. 


960 


The  Practice  of   Midwifery. 


can  be  felt  by  the  side  of  the  head  or  other  presenting  part.  The 
funis  is  then  said  to  be  j)rolapsed.  Prolapse  of  the  funis  may  also 
occur  for  the  first  time  at  the  moment  when  the  membranes  rupture, 
a  loop  of  it  coming  down  with  the  escape  of  the  liquor  amnii. 
There  is  yet  a  third  mechanism  by  which  prolapse  of  the  funis 
may  originate,  one  which  is  more  properly  called  expression  of  the 
funis.  In  this  case  the  funis  does  not  drop  down  passively,  but  is 
expelled  by  the  intra-uterine  pressure  through  some  space  left 
between  the  child  and  the  lower  segment  of  the  uterus.-^  The  pro- 
lapse then  usually  takes  place  for  the  first  time  at  a  considerable 

interval  after  the  rupture  of 
the  membranes,  labour  being 
obstructed  by  disj^roportion 
between  the  child  and  the  pelvic 
brim.  The  same  mechanism 
of  expression  may,  however, 
come  into  action  after  the  funis 
has  been  artificially  returned 
into  the  uterus  in  a  case  in 
which  the  first  prolapse  was  of 
a  passive  character. 

Causation.  —  The  reason 
why  prolapse  of  the  funis  does 
not  take  place  more  often  is 
that  the  lower  segment  of  the 
uterus  is  occujDied  by  the  head, 
which  is  closely  adapted  to  it. 
Hence  the  most  important 
cause  of  prolapse  of  the  funis 
in  head  presentation  is  deformity  of  the  pelvis,  especially  flattening 
of  the  brim  (40  per  cent,  of  the  cases,  Von  Winckel).  This  prevents 
the  head  from  descending  low  enough  into  the  pelvis  to  rest  closely 
upon  the  cervix  during  dilatation,  whilst  vacant  space  is  left  opposite 
the  sacro-iliac  articulations  through  which  the  funis  can  descend. 
(See  Fig.  363,  p.  726.)  In  pelvic  and  still  more  in  transverse 
presentations  prolapse  of  the  funis  is  also  promoted  by  the  fact 
that  the  presenting  part  does  not  so  accurately  fill  up  the  cervix  as 
the  head  would  do,  and  that  the  umbilicus,  in  these  cases,  is  nearer 
to  the  OS  uteri.     With  prolapse  of  the  funis,  Von  Winckel  ^  found 

1  See   Eoper,    Trans.    Obst.    Soc.   London,   1875,  Vol.   XVII, ,    p.  318;    Matthews 
Duncan,  Trans.  Obst.  Soc.  London,  1879,  Vol.  XXL,  p.  302. 
'^  Von  Winckel,  Klin.  Beobachtungen  zur  Path,  der  Geburt,  Rostock,  1869,  p.  220. 


Fig.  472. — Prolapse  of  the  funis,  with  the 
head  in  the  first  position. 


Accidents  during  and  after  Labour.       961 

cephalic  presentations  in  56'9  per  cent.,  pelvic  in  25*2  per  cent., 
shoulder  in  17*5  per  cent.,  and  face  in  1  per  cent,  of  the  cases. 
Other  causes  predisposing  to  prolapse  are  excessive  length  of  the 
funis,  low  insertion  of  the  placenta,  low  implantation  of  the  funis 
in  battledore  placenta,  fibroid  tumours  of  the  uterus,  multiple  preg- 
nancies," dead  and  premature  children,  and  excess  of  liquor  amnii. 
Prolapse  is  commoner  in  parous  women  than  in  primiparge,  since 
in  the  latter  the  greater  tonicity  of  the  abdominal  walls  keeps  the 
head  more  closely  adapted  to  the  brim. 

Frequency. — The  frequency  varies  considerably  in  different 
countries,  and  in  different  lying-in  institutions.  The  occurrence  is 
probably  commoner  in  those  places  where  pelvic  contraction  is 
frequent.  The  frequency  has  been  variously  estimated  at  from  1  in 
70  to  1  in  400  deliveries.  In  the  Guy's  Hospital  Charity  (1863 — 
1875)  it  was  1  in  383  deliveries.  Churchill's  statistics  give  a 
frequency  of  1  in  245  deliveries. 

Diagnosis. — There  is  scarcely  anything  which  can  give  rise  to 
error  of  diagnosis  except  foetal  intestine  in  a  case  of  ectopia  of 
viscera.  When  the  funis  is  felt  to  pulsate  diagnosis  is  perfectly 
easy,  even  before  rupture  of  the  membranes.  If  the  funis  is  pulse- 
less and  flaccid,  it  may  generally  be  inferred  that  the  child  is  dead. 
The  child  may,  however,  be  capable  of  resuscitation  for  a  short 
time  after  the  funis  has  ceased  pulsating,  and  therefore  the  fcetal 
heart  should  always  be  listened  for,  to  complete  the  diagnosis. 
Pulsation  may  also  be  arrested  for  the  time  by  a  pain,  to  reappear 
during  the  interval.  If  the  pulsation  becomes  progressively  slower, 
it  is  a  sign  that  the  child's  life  is  becoming  endangered. 

Prognosis. — The  prognosis  is  very  unfavourable  for  the  child, 
especially  in  head  presentations.  The  mortality  in  general  is  at 
least  50  ^er  cent.,  but  it  varies  much  according  to  the  stage  at 
which  a  case  first  comes  under  observation,  and  the  treatment 
adopted.  In  pelvic  presentations  the  danger  is  considerably  less. 
There  is  no  danger  to  the  mother,  except  such  as  may  result  from 
efforts  to  save  the  life  of  the  child. 

Treatment. — Before  Rupture  of  the  Membranes. — In  the  first 
stage  of  labour,  the  great  object  is  to  defer  the  rupture  of  the 
membranes  until  the  os  is  quite  fully  dilated.  For  this  purpose 
the  patient  should  be  kept  recumbent,  and  directed  to  avoid  any 
bearing-down  efforts.    She  may  be  placed  in  the  semi-prone  position, 

M.  61 


962  The  Practice  of   Midwifery.    • 

on  the  opposite  side  to  that  on  which  the  funis  has  descended.  No 
attempt  should  be  made  to  push  back  the  funis  through  the  mem- 
branes. The  attempt  is  not  Hkely  to  succeed,  and  may  possibly 
cause  rupture  of  the  membranes.  The  only  method  of  restoration 
which  may  be  attempted  with  advantage  at  this  stage,  provided 
that  the  foetus  is  alive,  is  the  postural  method.  If  the  woman 
is  placed  upon  a  firm  mattress  in  the  knee-elbow  position,  so  that 
the  thighs  are  exactly  vertical,  and  the  chest  as  close  as  possible  to 
the  surface  of  the  mattress,  the  brim  of  the  pelvis,  and  therefore 
the  fundus  of  the  uterus,  will  be  directed  almost  vertically  down- 
ward. The  funis  will  then  tend  to  gravitate  away  from  the  os. 
The  i^atient  should  be  kept  in  this  position  during  two  or  three 
pains.  If  recession  of  the  funis  is  thus  obtained,  she  may  be  turned 
into  the  semi-prone  position  previously  described. 

As  a  rule  the  funis  is  not  exposed  to  pressure  as  long  as  the 
membranes  are  unruptured.  In  exceptional  cases,  however,  it 
may  be  so,  when  the  os  is  so  far  dilated  as  to  allow  onward  move- 
ment of  the  presenting  part  through  the  cervix  to  take  place, 
even  without  rupture  of  the  membranes,  as  in  such  a  case  as  that 
represented  in  Fig.  131,  p.  220.  The  ring  of  close  contact  which 
sometimes  divides  the  "  fore- waters  "  from  the  rest  of  the  liquor 
amnii  may  then  compress  the  funis.  In  such  circumstances,  if 
either  the  pulsation  of  the  funis,  or  the  rate  of  the  foetal  heart, 
is  found  to  be  becoming  slow,  the  membranes  should  be  ruptured, 
and  the  case  treated  by  one  of  the  methods  shortly  to  be 
described. 

Reposition  of  the  Funis. — If,  after  rupture  of  the  membranes, 
the  funis  is  found  without  pulsation,  and  no  foetal  heart  can  be 
heard,  no  treatment  directed  to  the  prolapse  should  be  adopted. 
If,  however,  the  funis  pulsates,  if  the  os  is  sufficiently  dilated,  and 
if  the  vagina  readily  allows  the  introduction  of  the  hand,  an 
attempt  should  be  made  at  manual  reposition  of  the  funis. 
Advantage  here  also  is  gained  by  putting  the  patient  in  the  knee- 
elbow  position.  The  hand  should  be  passed  within  the  cervix, 
laid  flat  against  the  head,  and  the  loop  of  funis  pushed  up  by 
the  tips  of  the  fingers  until  the  whole  of  it  is  completely  above 
the  head.  If  a  limb  can  readily  be  felt,  a  part  of  the  loop  may 
be  hung  over  it.  If  a  pain  comes  on,  the  hand  should  remain 
quiescent  until  it  has  passed  off.  Then  the  other  hand  should  be 
used  externall}^  to  press  the  head  down  into  the  brim.  At  this 
stage  the  patient  may  be  turned  into  the  semi-prone  position, 
the  internal  hand  gradually  withdrawn,  and  the  pressure  of  the 
external  hand  maintained  until  a  pain  comes  on,  and  assists  in 


Accidents  during  and  after  Labour.       963 


fixing  the  head  in  the  brim.  This  method  is  Hkely  to  SQCceed, 
unless,  through  deformity  of  the  pelvis,  there  is  a  space,  by  which 
the  funis  may  again  come  down.  If  the  patient  cannot  readily 
be  induced  to  adopt  the  knee-elbow  position,  the  semi-prone 
position  may  be  used  from  the  first  with  almost  as  much  advantage. 
This  method  of  reposition  is  useless  if  the  case  is  one  of  expression 
of  the  funis  at  a  considerable  interval  after  rupture  of  the  mem- 
branes, or  if  the  funis  is  found  to  come  down  again  after  complete 
reposition.  The  only  chance  for  the  child  is  then  to  extract  as 
quickly  as  possible. 

Extraction  by  Forceps  or  Version. — If  the  funis  cannot  be  replaced 
by  the  hand,  or  descends  again 
after  reposition,  or  if  the  hand 
cannot  readily  be  passed  into  the 
vagina,  the  best  plan,  if  the  cervix 
is  sufficiently  dilated,  is  to  extract 
by  forceps  or  version  as  rapidly  as 
is  possible  without  risking  injury 
to  the  mother.  Forceps  should  be 
preferred  if  the  dilatation  is  so 
complete  that  the  cervix  is  not 
likely  to  delay  delivery,  otherwise 
version  may  be  performed.  After 
the  foot  has  been  brought  down, 
the  funis  should  be  replaced,  if 
possible,  within  the  uterus,  and 
the  half-breech  at  once  drawn 
down  into  the  os,  so  as  to  fill  up 
the  space.  If  this  can  be  effected, 
delivery  need  not  be  hurried.  If 
a  loop  of  funis  still  remains  prolapsed  by  the  side  of  the  breech, 
delivery  must  be  hastened  by  traction  upon  the  leg,  a  watch  being 
kept  upon  the  pulsations  of  the  funis. 

Instrumental  Reposition. — If  the  membranes  rupture  and  the 
cord  prolapses  with  the  cervix  only  partially  dilated,  so  that 
manual  reposition  or  immediate  delivery  is  impossible,  an  attempt 
may  be  made  to  replace  the  cord  with  a  repositor.  This  method 
may  also  be  tried,  in  the  place  of  manual  reposition,  in  primiparse 
and  others  in  whom  a  narrow  vagina  renders  it  difficult  to  intro- 
duce the  hand.  A  repositor  may  be  improvised  in  the  following 
manner : — A  large-sized  gam-elastic  catheter  is  taken,  a  slit  is  cut 
near  the  end  of  it  opposite  the  eye,  and  a  loop  of  tape  passed 
through  the  eye  and  the  artificial  slit  (Fig.  473).     A  loop  of  funis  is 

61—2 


Fig.    473. — Gum-elastic    catheter 
adapted  as  funis  repositor. 


964  The  Practice  of   Midwifery. 

then  secured  in  the  tape,  but  not  so  tightly  as  to  compress  it.  The 
stylet  is  introduced  into  the  catheter,  and  by  its  aid  the  catheter  is 
passed  nearly  its  whole  length  into  the  uterus,  until  the  funis  is 
quite  out  of  reach.  The  stylet  is  then  withdrawn,  and  the  catheter 
left  in  place  until  after  the  delivery  of  the  head.  Koberton's  funis 
repositor  is  a  rod  of  gutta-percha,  having  a  hole  near  the  end,  and 
is  intended  to  be  used  in  the  same  way.  It  has  the  advantage  of 
being  longer  than  an  ordinary  catheter.  A  long  piece  of  whale- 
bone may  also  be  used  in  the  same  manner,  a  hole  being  cut  near 
the  extremity. 

If  the  pulsations  in  the  cord  are  good,  and  it  can  be  completely 
replaced  within  the  uterus  by  means  of  the  repositor,  the  latter 
may  be  left  in  situ  and  dilatation  of  the  cervix,  hastened  by  the 
introduction  of  a  Champetier  de  Eibes'  bag.  Unless  the  cord  can 
be  completely  replaced,  however,  the  bag  is  very  liable  to  compress 
the  latter,  and  in  any  case  where  the  cervix  is  only  partially  dilated 
the  chances  of  delivering  a  living  child  are  very  small. 

Treatment  in  Pelvic  Presentations. — In  breech  presentations  one 
leg  should  be  brought  down.  It  is  useful  to  fasten  a  noose  of 
tape  round  the  foot.  The  funis  should  then  be  pushed  up  as  far 
as  possible  into  the  uterus,  and,  by  means  of  the  tape,  the  half- 
breech  drawn  down  into  the  os,  so  as  to  fill  it  up,  before  the 
internal  hand  is  withdrawn.  If  this  does  not  succeed,  labour 
must  be  accelerated  by  traction  on  the  leg. 

Physometra  or  Tympanites  Uteri. 

Air  may  gain  access  to  the  uterus  during  obstetric  operations, 
especially  when  the  hand  is  introduced  into  the  uterus  for  version 
or  to  guide  the  application  of  extracting  instruments  in  cranio- 
tomy. In  these  circumstances,  if  the  child  is  becoming  somewhat 
asphyxiated  from  prolonged  pressure  it  may  attempt  to  breathe, 
and  even  to  cry,  producing  the  so-called  vagitus  uterinus.  I  have 
met  with  a  case  in  which  such  a  cry  was  heard  during  version 
performed  on  account  of  contraction  of  the  brim.  The  child  was 
still-born,  but,  on  post-mortem  examination,  partial  distension  of 
its  lungs  was  found,  such  as  would  generally  be  considered  as  proof 
of  live-birth.  This  medico-legal  test  of  live-birth  is  therefore  open 
to  possible  fallacy  in  these  circumstances. 

Even  without  the  performance  of  any  operation,  air  may  enter 
the  uterus  in  smaller  quantity,  replacing  some  of  the  liquor  amnii. 
When,  after  long  rupture  of  the  membranes,  the  greater  part  of 
that  fluid  has  drained  away,  and  air  has  entered,  carrying  with  it 


Accidents  during  and  after  Labour.        965 


gas-producing  bacteria,  decomposition  of  the  foetus  is  set  up  soon 
after  its  death,  and  this  goes  on  rapidly  in  presence  of  warmth 
and  moisture.  It  is  still  further  promoted  if  free  entry  of  air  has 
taken  place  in  attempts  at  operation.  From  decomposition  foetid 
gas  may  be  freely  produced,  and  if,  at  the  same  time,  the  uterus 
is  inactive  from  exhaustion,  it  may  become  distended  and  tym- 
panitic. Such  a  condition  is  always  a  grave  one  for  the  patient,  and 
generally  indicates  that  interference  has  been  too  long  deferred. 
The  presence  of  air  or  gas  within  the  uterus  involves  the  possi- 
bility of  sudden  death  through  the 
entrance  of  the  air  or  gas  into  the 
veins  (see  Chapter  XL.). 

Treatment. — The  uterus  should  be 
emptied  as  soon  as  possible  and  at 
once  washed  out  with  an  antiseptic 
fluid.  All  means  should  be  taken  to 
secure  firm  permanent  contraction  of 
the  uterus.  Uterine  irrigations  should 
be  continued  through  the  puerj)eral 
period,  if  there  are  any  unfavourable 
symptoms. 

Invbesion   of   the   Uterus. 

In  inversion  of  the  uterus,  the 
uterus  is  more  or  less  completely 
turned  inside  out,  so  that  its  peri- 
toneal surface  becomes  interior.  Into 
the  cavity  thus  formed  is  necessarily  drawn  more  or  less  of  the 
Fallopian  tubes,  ovarian  ligaments,  broad  and  round  ligaments ; 
sometimes  also  the  ovaries  themselves.  Inversion  may  exist 
in  three  stages  :  in  the  first,  the  fundus  is  partially  inverted, 
but  does  not  pass  through  the  external  os ;  in  the  second,  the 
inverted  fundus  passes  through  the  os  into  the  vagina  but  the 
inversion  is  still  incomplete  ;  in  the  third,  the  inversion  is  complete, 
so  that  there  is  no  longer  any  groove  round  the  neck  of  the  tumour 
formed  by  the  inverted  uterus.  Either  the  second  or  third  stage 
may  be  complicated  by  prolapse  of  the  inverted  fundus  through  the 
vulva.  In  other  instances  the  inversion  may  begin,  not  at  or  near 
the  fundus,  but  lower  down  in  the  uterine  wall,  and  one  wall  may 
become' inverted  before  the  other.  In  this  case,  a  section  of  the 
uterine  wall  forms  an  S- shaped  curve,  while  the  inversion   is   in 


Fig.  47-1:. — Commencing  inversion 
of  the  uterus,  from  a  prepara- 
tion in  the  Museum  of  Guy's 
Hospital. 


966 


The  Practice  of   Midwifery. 


course  of  production.     Inversion  may  be  produced  either  before  or 
after  the  expulsion  of  the  placenta. 

Causation. — For  the  production  of  inversion,  it  is  essential  that 
there  should  be  inertia,  either  complete  or  partial,  of  the  uterine 
wall.^  In  some  cases  inversion  is  produced,  or  at  any  rate  initiated, 
by  the  interference  of  the  accoucheur.     This  may  be  done,  when  the 


Fig.  475. — Complete  inversion  of  uterus  with  prolapse, 
attached.     (Bumm. ) 


The  placenta  still 


uterus  is  relaxed,  either  by  injudicious  traction  on  the  funis,  the 
placenta  being  adherent,  or  by  a  too  localised  downward  pressure 
upon  the  fundus  employed  either  to  expel  the  placenta,  or  to  stimu- 
late uterine  contraction.  In  other  cases  inversion  is  entirely 
spontaneous.  Here  also  there  must  be  relaxation  at  any  rate  of 
the  part  of  the  uterine  wall  at  which  the  inversion  commences, 
often  the  placental  site.  A  bulging  inward  may  be  the  result 
simply  of  gravity,  especially  through  the  weight  of  a  still  attached 

1  See  Bar,  Bull,  de  la  Soc.  d'Obst.  de  Paris,  1902,  Vol.  V.,  p.  2. 


Accidents  during  and  after  Labour.       967 

placenta.  Or  it  may  be  the  effect  of  a  bearing-down  effort, 
especially  when  made  in  an  upright  position,  as  for  micturition 
or  defaecation,  shortly  after  delivery.  Such  a  bearing-down  effort 
may  complete  the  inversion,  if  the  uterus  is  entirely  relaxed.  But 
it  appears  that,  in  spontaneous  inversion,  a  partial  contraction  of 
the  uterus  itself  often  aids  in  the  process.  The  relaxed  and 
partially  inverted  fundus,  bulging  into  the  cavity,  excites  the  lower 


Ov. 

Fig.  476. — Sagittal  section  of  pelvis  with  complete  inversion  of  the  uterus. 
Bl.,  bladder  ;  Sy.,  symphysis  pubis  ;  Oc,  ovary  ;  L.r.,  round  ligament  ; 
O.e.,  OS  externum  ;  Tu.,  Fallopian  tube  ;  It.^  inversion  ring.  (R.  v. 
Braun  Fernwald,  Von  Winciiel's  Handbuch  der  GeburtshUlfe,  Bd.  III., 
Th.  II.,  p.  1.57.) 

part  of  the  uterus  to  contract,  as  a  foreign  body  would,  and  by  this 
means  is  expelled  through  the  os.  The  mechanism  is  the  same  as 
that  by  which  a  commencing  intussusception  is  increased  by 
intestinal  contraction.  The  patient  also  feels  the  sensation  as  of  a 
foreign  body  which  has  to  be  expelled,  and  is  thereby  stimulated  to 
a  bearing-down  effort,  which  aids  in  completing  the  inversion. 

The  bulging  inward  of  the  placental  site,  which  is  the  first  step 
towards  inversion,  may  be  produced  even  before  delivery  in  con- 
sequence of  shortness  of  the  funis,  either  absolute  or  due  to  the 


968  The  Practice  of   Midwifery. 

funis  being  twisted  round  the  neck.^  This  will  happen  the  more 
readily  if  the  delivery  is  aided  by  forceps.  Its  spontaneous  occur- 
rence must  generally  imply  some  irregularity  in  the  uterine  con- 
traction, since  a  firm  contraction  of  the  whole  fundus  renders 
inversion  impossible.  If,  however,  delivery  takes  place  in  an 
upright  j)osition,  inversion  may  be  produced  by  the  weight  of  the 
child  acting  through  the  funis,  while  the  uterus  is  relaxed.  An 
insertion  of  the  placenta  exactly  at  the  fundus,  instead  of  on  the 
anterior  or  posterior  uterine  wall,  has  been  thought  to  be  a  pre- 
disposing cause  of  inversion,  since  the  relaxed  placental  site  is  then 
more  likely  to  bulge  into  the  uterine  cavity  like  a  polypus.  Inver- 
sion generally  happens  very  soon  after  delivery,  and  more  frequently 
before  than  after  the  expulsion  of  the  placenta.  If  observed  at  a 
later  stage,  it  is  more  generally  gradual  in  its  production.  I  have 
met  with  a  case  in  which  it  was  produced  two  days  after  delivery  as 
the  patient  was  sitting  uj)  to  pass  urine.  But  in  cases  of  this  kind 
it  is  probable  that  a  partial  inversion  may  have  existed  from  an 
earlier  stage.  Inversion  has  been  recorded  after  delivery  in  the 
earlier  months  of  pregnancy,  but  much  less  frequently  than  at  full 
term.  Apart  from  pregnancy,  it  may  be  produced  by  traction  of  a 
tumour. 

Frequency.  —  Inversion  of  the  uterus  is  very  rare.  Only  1 
case  was  observed  in  190,833  deliveries  at  the  Eotunda  Hospital, 
Dublin.  Jardine^  records  3  cases  among  51,290  cases  in  the 
Glasgow  Maternity  Hospital  with  2  recoveries. 

Symptoms  and  Results. — The  symptoms  of  inversion  are  shock 
and  haemorrhage.  The  shock  is  due  mainly  to  the  strangulation  of 
the  uterus  and  the  traction  on  the  broad  ligaments.  It  is  shown  by 
pain,  rapid  feeble  pulse,  anxious  expression,  and  often  vomiting. 
The  haemorrhage  is  due  partly  to  the  uterine  inertia,  which  allowed 
the  inversion,  partly  to  the  strangulation  impeding  the  return  of 
venous  blood  from  the  fundus.  If  the  inversion  is  produced  gradu- 
ally, shock  is  less  manifest,  and  haemorrhage  the  main  symptom. 
If  the  inversion  is  left  unrestored,  haemorrhage  is  apt  to  persist  and 
recur,  especially  when  menstruation  recommences.  I  have  known 
a  woman  to  remain  free  from  haemorrhage  or  other  symptoms  for 
many  months  as  long  as  she  was  suckling,  but  to  begin  to  suffer 
from  serious  haemorrhage  as  soon  as  she  weaned  her  baby.     More 

-1  Dyhrenfurth,   Zentralbl.  f.  Gynak.,  1885,  No.  51,  p.  801  ;  Dighton  and  Collins, 
Jouru.  Obst.  and  Gyn.  Brit.  Emp.,  Vol.  VIIL,  No.  4,  p.  250. 
2  Jardine,  Clinical  Obstetrics,  1910,  p.  494. 


Accidents  during  and  after  Labour.        969 

or  less  inflammation  of  the  surface  of  the  inverted  uterus  also 
follows.  Hence  arises  semi-purulent  discharge,  and  sometimes 
sloughing  and  septicaemia.  The  presence  of  the  tumour  in  the 
vagina  also  sets  up  bearing-down  efforts,  with  rectal  and  vesical 
tenesmus.  Eventually,  in  some  cases,  toleration  is  established  to  a 
great  extent,  and  women  have  lived  for  many  years  with  an  inverted 
uterus.  But  death  may  result  from  haemorrhage  even  at  a  con- 
siderable interval  after  the  first  occurrence  of  the  accident. 

Prognosis. — In  a  considerable  proportion  of  cases,  death  results 
from  haemorrhage  aided  by  shock,  generally  within  half  an  hour  or 
an  hour  after  the  accident.  According  to  Crosse,^  a  fatal  result 
follows  within  a  few  hours  in  about  28  per  cent,  of  the  cases, 
sooner  or  later  in  about  42  per  cent.  In  about  7  per  cent,  death 
took  place  after  more  than  a  year's  interval.  In  23  cases  collected 
by  Munro  Kerr,  death  occurred  in  6,  or  28  per  cent.  Beckmann,^ 
however,  reports  a  mortality  of  only  14  per  cent,  in  cases  treated 
by  immediate  replacement. 

Diagnosis. — In  recent  inversion  diagnosis  is  easy.  Before  the 
separation  of  the  placenta  no  mistake  can  possibly  be  made.  After 
its  separation,  the  inverted  uterus  could  only  be  mistaken  for  a 
fibroid  tumour  or  fibroid  polypus.  It  is  distinguished  from  these 
by  the  absence  of  the  fundus  uteri  from  its  normal  position  in  the 
hypogastrium.  The  diagnosis  may  be  made  by  abdominal  exami- 
nation alone  if  the  accoucheur,  on  placing  his  hand  on  the  abdomen 
shortly  after  delivery,  fails  to  feel  any  fundus  uteri ;  but  can  pass 
his  hand  down  deeply,  and  feel  the  promontory  of  the  sacrum.  It 
will  then  be  easily  verified  by  vaginal  examination.  If  any  unusual 
pain,  or  symptoms  of  shock,  or  haemorrhage  are  observed  shortly 
after  delivery,  a  vaginal  examination  should  never  be  omitted ; 
otherwise  an  inversion  of  the  uterus,  partial  or  even  complete, 
may  be  overlooked.  The  diagnosis  in  the  chronic  stage  belongs  to 
gynaecology. 

Treatment. — If  the  case  is  recognised  at  once,  reduction  should 
be  effected  as  soon  as  possible,  without  more  delay  than  is  necessary 
to  give  some  brandy,  or  a  subcutaneous  injection  of  ether,  if  there 
is  great  collapse.  If  the  placenta  is  still  completely  attached,  it 
should  be  left  as  a  protection  to  the  uterus  and  to  avoid  further 
haemorrhage,  but  if  it  is  partly  detached,  it  should  be  peeled  off 

1  "An  Essay  on  [nversio  Uteri,"  Trans,  of  the  Provincial  Med.  and  Surg.  Assoc, 
1847. 

2  Zeitschr.  f.  Geb.  u.  Gyn.,  1895,  lid.  :jl.  p.  :}71. 


970 


The  Practice  of   Midwifery. 


first,  because  the  size  of  the  mass  to  be  returned  is  by  that  means 
considerably  reduced. 

In  carrying  out  the  taxis,  counter-pressure  is  to  be  made  with 
the  external  hand,  to  prevent  too  great  stretching  of  the  uterine 
attachments.  The  fundus  should  not  be  indented,  for  then  four 
thicknesses  of  the  uterine  wall  instead  of  two  would  have  to  be 
passed  through  the  cervix.  The  uterus  should  be  returned  in  the 
same  way  as  that  in  which  it  came  down.     For  this  purpose,  the 

fundus  may  be  grasped  in  the  palm 
of  the  hand  and  pressed  upwards. 
When  it  has  been  elevated  as  far 
as  possible  in  this  way,  pressure 
may  be  made  upon  the  fundus 
with  the  closed  fist.  At  each 
stage,  the  direction  of  pressure 
must  be  that  of  the  pelvic  axis. 
If  resistance  is  met  with  at  the 
final  stage,  after  the  fundus  has 
been  returned  through  the  external 
OS,  advantage  may  be  derived 
from  the  method  recommended 
by  Noeggerath,  namely,  to  make 
pressure  with  one  or  two  fingers 
near  the  orifice  of  the  Fallopian 
tube,  and  so  restore  one  corner  of 
the  uterus  first.  If  the  reduction 
is  prevented  by  contraction  of 
Bandl's  ring,  an  anaesthetic  should 
be  given,  if  the  condition  of  the 
patient  will  allow  it,  and  the 
operation  will  thus  be  greatly 
facilitated. 

If  the  inversion  is  only  discovered  at  some  interval  after  delivery 
an  attempt  at  reduction  by  taxis,  with  the  assistance  of  an  anaes- 
thetic, may  still  be  made,  if  involution  has  not  progressed  far.  If  the 
attempt  fails,  the  case  must  be  treated  as  one  of  chronic  inversion. 
The  same  plan  may  be  adopted  from  the  outset,  if  more  than  two  or 
three  days  have  passed  since  delivery,  and  the  base  of  the  uterine 
tumour  appears  to  be  small  and  firmly  contracted.  Inversion  is 
regarded  as  chronic,  when  the  process  of  involution  has  become 
complete. 

Elastic  Pressure. — The  best  treatment  for  chronic  inversion  is 
gradual  elastic  pressure  by  means  of  Aveling's  repositor.       This 


Fig.  477. — Modified  Aveling's  I'epositor 
for  inversion  of  uterus. 


Accidents  during  and  after  Labour.       971 

consists  of  an  S-shaped  stem  with  double  curve,  pelvic  and  perineal, 
surmounted  by  a  cup  which  receives  the  inverted  fundus  (Fig.  478). 
By  means  of  this  repositor  pressure  can  be  made  always  in 
the  correct  direction,  along  the  pelvic  axis,  just  as  axis  traction 
is  made  by  Tarnier's  forceps,  which  it  resembles  in  shape.  The 
pressure  is  exercised  by  four  elastic  rings,  fastened  by  bands  to  a 
waistbelt,  which  is  again  supported  by  shoulder  straps.  By  means 
of  these,  the  direction  and  degree  of  the  pressure  can  be  exactly 
regulated.  The  instrument  is  made  with  cups  of  two  or  three 
sizes,  which  can  be  screwed  on  at  the  top.      The  largest  cup  is 


Fig.  478. — Modified  Aveling's  repositor  applied  for  reduction  of  inverted  uterus. 

used  while  the  inverted  fundus  is  in  the  vagina.  It  may  be 
changed  for  a  smaller  one  when  the  fundus  has  passed  up  to  the 
level  of  the  vaginal  roof.  There  is  one  drawback  to  Aveling's 
instrument,  namely,  that  the  restoration  is  often  suddenly  com- 
pleted in  the  middle  of  the  night.  When  the  patient  is  visited 
next  day,  the  internal  os  has  contracted  beneath  the  shallow  cup, 
and  there  is  much  difficulty  in  extracting  the  cup  out  of  the  uterus. 
To  obviate  this  I  have  had  a  modification  of  the  instrument  con- 
structed in  which  the  smaller  cup  forms  the  summit  of  a  cylinder 
12  inches  long.  When  the  restoration  is  complete,  the  cylinder 
keeps  the  internal  os  dilated,  and  is  easily  withdrawn.  The  external 
OS  does  not  contract  for  a  few  hours.    The  cylinder  is  also  perforated 


972  The  Practice  of   Midwifery. 

by  a  small  hole,  to  prevent  its  withdrawal  being  hindered  by 
atmospheric  pressure. 

The  position  in  which  the  instrument  lies,  when  the  bands  are 
tightened  up,  is  shown  in  Fig.  478,  p.  971.  The  bands  may 
require  further  tightening,  after  a  few  hours,  as  the  uterus  ascends  ; 
and  morphia  must  be  given,  if  much  pain  is  produced.  In  a  con- 
siderable number  of  cases  the  inverted  uterus  has  been  removed, 
when  reduction  has  been  found  impossible.  It  is  probable  that 
this  will  hardly  ever  prove  necessary  if  a  fair  trial  is  given  to  elastic 
pressure  with  a  proper  repositor.  I  have  never  known  restoration 
fail  to  be  completed  within  forty-eight  hours.  Even  if  reposition 
fails  it  will  usually  be  possible  to  re-invert  the  uterus  by  practising 
one  or  other  of  the  operations  which  have  been  devised  for  this 
purpose. 

In  attempting  reduction  with  an  Aveling's  repositor,  at  a  stage 
intermediate  between  the  acute  and  chronic,  within  a  week  after 
delivery,  I  have  found  even  the  largest  cup  slip  aside,  being  too 
small  for  the  fundus.  But  success  was  at  once  attained  when  an 
extra-sized  cup  had  been  made  to  fit  the  fundus. 

Occasionally  if  attempts  at  replacement  fail,  and  the  patient  be 
left  alone,  spontaneous  reinversion  occurs,  as  in  a  case  recorded  by 
Boxall.i 

1  Trans.  Obst.  Soc.  London,  190i,  Vol.  XLVI.,  p.  292. 


Chapter  XXXVIIL 

RETENTION    OF    THE    PLACENTA    AND    POST- 
PARTUM  HEMORRHAGE. 

Eetention  of  the  Placenta. 

Causation. — Eetention  of  the  placenta  may  arise  from  inertia 
of  the  uteruSj  from  morbid  adhesion  of  the  placenta  or  membranes 
to  the  uterine  wall,  or  from  the  so-called  hour-glass  contraction  of 
the  uterus,  a  condition  always  associated  with  more  or  less  inertia 
of  the  fundus.  Any  of  these  causes  existing,  retention  is  also 
promoted  by  unusually  large  size  of  the  placenta,  by  over-distension 
of  the  bladder,  or  by  deviation  of  the  uterine  axis  from  that  of  the 
pelvis. 

Inertia. — Normally  the  shrinking  of  the  uterus  on  the  expulsion 
of  the  foetus  separates  the  placenta  partially,  and  perhaps  some- 
times wholly  (see  pp.  281 — 287).  If  the  uterus  afterwards  remains 
inactive,  the  placenta  may  be  retained,  notwithstanding  that  it  is 
separated  or  almost  entirely  separated.  The  laxity  of  the  uterus 
may  be  sufficient  to  cause  post-partujn  hgemorrhage,  or  there  may 
be  sufficient  tonic  contraction  to  prevent  excessive  bleeding,  but  no 
rhythmical  pain  strong  enough  to  expel  the  placenta  and  separate 
the  remaining  shreds  of  attachment.  In  general,  when  the 
placenta  is  long  retained  from  inertia,  the  bleeding  is  greater  than 
normal.  The  blood  is  then  apt  to  collect  behind  the  placenta  and 
invert  it  in  the  manner  shown  in  Fig.  195,  p.  286.  When  this 
occurs  spontaneously,  or  when  it  is  produced  by  traction  on  the 
funis,  the  difficulty  of  the  expulsion  of  the  placenta  is  increased. 
For  the  placenta,  when  in  the  form  of  an  inverted  umbrella,  forms 
a  larger  mass  to  pass  through  the  os  than  when  folded  longitu- 
dinally on  itself  in  the  natural  manner  as  shown  in  Fig.  194,  p.  286. 
The  degree  of  inertia  necessary  to  cause  retention  is  relative  to 
the  firmness  of  attachment  of  the  placenta  to  the  uterus.  A  slight 
excess  of  firmness  at  some  remaining  points  of  attachment,  which 
would  be  broken  down  by  a  strong  contraction,  will  suffice  to  cause 
retention  if  contraction  is  feeble.  Inertia  of  the  uterus  is  of  course 
more  likely  to  exist  in  the  absence  of  the  stimulation  by  external 
pressure  and  friction  usually  employed  in  the  third  stage  of  labour. 


974 


The  Practice  of   Midwifery 


Adhesion  of  the  Placenta. — The  separation  of  the  placenta 
normally  takes  place  through  that  layer  of  the  decidua  basalis 
which  forms  an  open  network  of  areolar  spaces  due  to  the  dilatation 
of  the  uterine  glands  (see  p.  76).  Morbid  adhesion  occurs  from 
failure  in  the  development  of  this  areolar  layer,  or  its  replacement 
by  fibrous  tissue,  or  from  unusual  firmness  of  the  bands  forming 
the  trabeculse.     Any  of  these  conditions  is  usually  the  result  of 


Fig.  479. — Uterus  with  adherent  cotyledon  of  placenta  from  patient  dying  of 
post-partum  and  ante-partum,  haemorrhage.  (Univ.  Coll.  Hosp.  Med. 
School  Mus.). 


previous  endometritis,  which  may  be  syphilitic  or  not.  The 
endometritis  leads  to  excess  of  fibrous  tissue  in  the  decidua  basalis, 
and  this  condition  and  the  consequent  adhesion  of  the  placenta  are 
apt  to  be  repeated  in  successive  pregnancies.  In  some  cases  the 
adhesion  has  been  found  to  be  due  to  complete  absence  of  the 
compact  as  well  as  the  areolar  layer  of  the  decidua,  the  villi  being 
directly  connected  with  the  muscular  wall  of  the  uterus.  ^  This 
may  be  the  consequence  of  degeneration,  rather  than  inflammation, 

1  Langhans,  Arch.  f.  Gyn.,  1875,  Bd.  8,  p.  295. 


Retention   of  the  Placenta,   Etc.  975 

of  the  endometrium  previous  to  pregnancy.  It  is  dijfficult  for  the 
great  shrinking  of  the  placental  site  which  accompanies  the 
expulsion  of  the  foetus  to  occur  without  some  separation  of  the 
placenta.  Accordingly  the  adhesion  is  almost  always  found  to  be 
partial,  the  tracts  of  firmest  attachment  having  alone  resisted  the 
effects  of  uterine  shrinking.  Haemorrhage  may  occur  from 
the  placental  site  at  the  separated  portion.  Adhesion  of  the 
placenta  is  thus  one  of  the  causes  of  j^ost-partitm  hgemorrhage,  for 
the  haemorrhage  is  promoted  by  the  presence  of  the  placenta 
within  the  uterus  preventing  complete  retraction  and  closure  of  the 
vessels.  Its  resistance  to  expulsion  is  also  liable  to  set  up  irregular 
contraction,  one  part  of  the  uterus  remaining  lax  and  allowing 
haemorrhage  while  another  is  contracted. 

Adhesion  of  the  placenta  at  full  term  sufficient  to  make  artificial 
separation  a  necessity  is  a  rare  condition.  It  is  apt  to  be  inferred 
when  it  does  not  really  exist,  if  the  third  stage  of  labour  is  badly 
managed,  and  the  placenta  is  brought  away  piecemeal  by  the  hand. 

Adhesion  of  the  Chorion. — Eetention  of  the  placenta  may  also  be 
produced  by  undue  adhesion  of  the  chorion  to  the  uterine  wall, 
especially  when  this  exists  around  the  edge  of  the  placenta.  The 
placenta  is  then  specially  apt  to  be  inverted  by  blood  effused  behind 
it  which  does  not  escajDe  externally.  If  the  adhesion  of  the  chorion 
is  at  a  greater  distance  from  the  edge  of  the  placenta,  the  placenta 
may  be  arrested  when  partially  expelled  into  the  vagina.  Adhesion 
of  the  chorion  is  generally  due  to  previous  endometritis  affecting 
that  part  of  the  uterus  occupied  by  the  decidua  vera. 

Diagnosis  of  Adhesion. — There  are  no  reliable  signs  during  preg- 
nancy of  adhesion  of  the  placenta.  It  may  be  expected  as  probable 
if  it  has  been  found  more  than  once  in  previous  deliveries.  Some- 
times there  is  during  pregnancy  pain  referred  to  the  fundus  uteri, 
and  produced  by  the  inflammatory  condition  of  the  uterine  wall. 
After  delivery,  adhesion  may  be  suspected  if  good  uterine  con- 
tractions appear  to  occur  without  any  descent  of  the  placenta  for  a 
considerable  time.  In  the  very  rare  instance  of  complete  adhesion 
there  may  be  an  absence  even  of  the  usual  sanguineous  discharge. 
This  is  rarely  observed  except  in  cases  of  abortion  or  premature 
labour,  where  the  placental  site  is  smaller  and  has  therefore  a  better 
chance  of  resisting  detachment  through  the  uterine  shrinking. 
More  frequently  there  is  a  gush  of  blood  with  each  pain,  indicating 
a  partial  detachment  of  the  placenta.  If  traction  is  made  upon 
the  funis  with  an  adherent  placenta,  the  whole  uterus  descends, 
the  placenta  not  advancing,  and  pain  is  produced  at  the  fundus. 
Such  traction  should,  however,  never  be  made.      The  only  positive 


976 


The  Practice  of  Midwifery. 


mode  of  diagnosis  is  to  feel  the  adhesion  when  the  hand  is  passed 
into  the  uterus  for  removal  of  the  placenta. 

Hour-glass  Contraction  of  the  Uterus. — The  placenta  may  be 
retained  in  consequence  of  spasmodic  contraction  of  the  lower  part 
of  the  body  of  the  uterus  associated  with  inertia  of  the  upper  part, 
especially  of  the  placental  site.  There  are  two  forms  of  such 
contraction.     In  the  commoner,  and  that  which  most  completely 


Fig.  480. — Eetained  placenta  from  hour-glass  contraction  of  uterus. 
(Bumm,  Grundriss  der  Geburtshilfe.) 

deserves  the  name  of  "  hour-glass  contraction,"  the  part  of  the 
uterus  spasmodically  contracted  is  the  internal  os,  the  circular 
fibres  around  which  form  a  sort  of  sphincter  for  the  uterine  cavity, 
and  are  the  most  ready  to  contract  again  after  dilatation.  The 
hand  when  introduced  then  feels  a  sharp  ring  of  contraction.  It 
is  probable  that  many  observers  describing  "  hour-glass  con- 
traction" have  not  realised  to  what  a  height  the  internal  os  is 
raised,  owing  to  the  elongation  of  the  cervix  by  stretching,  and, 
accordingly,  have  supposed  the  constriction  to  be  at  a  higher  level 


Retention  of  the  Placenta,   Etc.  977 

in  the  body  of  the  uterus.  In  other  cases  there  really  is  a  con- 
traction of  the  part  of  the  body  of  the  uterus  below  the  placenta, 
possibly  of  Bandl's  ring,  with  atony  of  the  placental  site,  so  that 
the  placenta  becomes  encysted.  This  condition  is  apt  to  be  reached 
if  a  more  or  less  adherent  placenta  is  allowed  to   remain  for  a 


Fig.  481. — Eemoval  of  an  adherent  placenta. 

considerable  number  of  hours  after  delivery.  There  is  generally 
not  such  a  limited  sharp  ring  of  contraction,  and  the  term  "  hour- 
glass contraction  "  is  therefore  not  so  fully  suitable. 

Causation  of  Spasm. — The  spasmodic  contraction  of  the  uterus  is 
analogous  to  the  spasmodic  rigidity  of  the  cervix  in  the  first  stage 
of  labour,  and,  like  it,  is  always  associated  with  an  absence  of  active 
expulsive  pains.     It  may  be  a  sequel  of  spasm  during  labour,  and 

M.  62 


978  The  Practice  of   Midwifery. 

depend  upon  the  same  constitutional  conditions.  It  may  also  be  set 
up  after  delivery  by  irritation  of  the  uterus  jDroduced  by  traction  on 
the  funis,  by  resistance  of  the  placenta  to  exj)ulsion  owing  to  morbid 
adhesion,  or  it  may  be  produced  by  the  administration  of  ergot.  In 
both  spasm  of  the  cervix  in  labour  and  in  hour-glass  contraction 
there  is  a  disturbance  of  the  natural  nervous  relations  ;  and,  in  both, 
the  so-called  "  polarity  "  of  the  uterus  (see  p.  212)  has  been  said  to 
be  modified.  If  an  active  expulsive  pain  occurs,  the  circular  fibres 
are  not  only  distended  by  the  advance  of  the  placenta  but  undergo 
physiological  relaxation.  An  atony  of  the  placental  site,  with  con- 
traction of  other  parts  of  the  uterus,  similar  to  that  which  occurs  in 
hour-glass  contraction,  maybe  the  starting-jDoint  of  inversion  of  the 
uterus.  In  cases  of  complete  encystment  of  the  placenta  by  con- 
traction of  the  whole  of  the  body  of  the  uterus  below  its  level,  I 
have  generally  found  that  some  morbid  adhesion  existed  as  a  cause 
of  the  spasm. 

Prophylaxis. — Retention  of  the  placenta  is  best  avoided  by  the 
judicious  management  of  the  third  stage  of  labour,  and  is  therefore 
apt  to  be  much  commoner  in  the  practice  of  the  inexperienced  than 
in  that  of  skilled  accoucheurs.  It  is  especially  important  not  to 
make  jDremature  attempts  to  deliver  the  placenta,  not  to  irritate  the 
uterus  by  traction  on  the  funis,  and  to  use  external  pressure  for 
expulsion  only  when  the  uterus  hardens  with  a  pain,  repeating  it, 
if  necessary,  with  successive  pains. 

Treatment.— If  there  is  no  hfemorrhage  of  consequence,  a  fair 
trial  should  be  given  to  the  method  of  expression  described  in  the 
chapter  on  the  management  of  normal  labour.  If  there  is  haemor- 
rhage, the  placenta  should  be  removed  at  once.  If  the  method  of 
expression  fails,  the  hand  should  be  introduced  for  removal  without 
any  attempt  to  extract  by  pulling  the  funis.  For  this  purpose  the 
patient  should  be  placed  upon  her  back,  and  the  gloved  hand  passed 
up  into  the  uterus,  the  fundus  being  supported  by  the  other  hand 
externally.  If  there  is  any  constriction,  it  must  be  gradually 
dilated  by  the  fingers  in  the  form  of  a  cone.  If  the  placenta  is 
found  quite  loose  in  the  cavity,  it  has  simply  to  be  grasped  and  drawn 
down.  If  any  attachment  is  found,  it  must  be  separated  by  passing 
the  fingers  side  by  side  between  the  placenta  and  the  uterine  wall, 
the  dorsal  surface  towards  the  uterus.  Hence,  if,  as  is  usually  the 
case,  the  placenta  is  found  attached  to  the  posterior  wall,  it  is  most 
convenient  to  begin  detachment  at  the  lower  margin,  the  fingers 
being   passed   ujpwards   and   from  side  to  side  until  the  whole  is 


Retention  of  the  Placenta,   Etc.  979 

separated.  The  placenta  is  then  easily  grasped  by  the  hand  and 
withdrawn.  If  the  placenta  is  attached  to  the  anterior  wall,  the 
hand  must  be  passed  up  to  the  fundus  first,  and  separate  it  from 
above  downwards  by  the  tips  of  the  flexed  fingers. 

In  the  case  of  extensive  and  firm  adhesion  great  care  is  necessary. 
The  surface  of  separation  will  then  probably  be  not  in  the  decidua 
basalis  but  in  the  placental  tissue  itself.  The  main  mass  of  placenta 
should  first  be  separated  in  the  way  already  described.  Then  the 
hand  should  be  introduced  again,  and  any  separate  pieces  of 
placental  tissue  broken  down  by  the  pulp  of  the  fingers  and 
removed.  It  is  better  to  leave  small  shreds  of  roughness  attached 
than  to  injure  the  uterine  wall.  After  firm  adhesion  of  the 
placenta,  it  is  generally  desirable  to  wash  out  the  uterine  cavity 
with  a  warm  antiseptic  douche  such  as  lysol  1  per  cent,  or  iodine 
5j.  to  5ij.  to  the  pint,  after  its  removal. 

If  there  has  been  previous  haemorrhage,  the  use  of  an  anaesthetic 
should  be  avoided  if  possible.  In  any  case  ether  is  preferable  to 
chloroform,  as  causing  less  complete  and  less  prolonged  relaxation 
of  the  uterus  ;  and  the  anaesthesia  should  not  be  deeper  than  is 
necessary  to  allow  the  requisite  manipulation.  In  the  case,  how- 
ever, of  a  tight  hour-glass  contraction  the  effect  of  the  anaesthetic 
in  overcoming  spasm  may  be  essential,  and  chloroform  may,  in  this 
instance,  have  the  advantage. 

POST-PARTUM    H^MOREHAGE. 

Haemorrhage  after  delivery  may  come  from  various  sources. 
Haemorrhage  from  the  placental  site  is,  however,  so  much  the  most 
frequent  and  most  important,  that  this  is  regarded  as  post-partum 
haemorrhage  _29ar  excellence.  The  subject  is  one  of  immense  im- 
portance, for  post-partum  haemorrhage  is  one  of  the  most  dangerous 
complications  of  parturition.  It  may  occur  after  the  most  perfectly 
normal  labour,  and  a  household  may  thus  be  unexpectedly  plunged 
into  grief  by  the  sudden  death  of  the  patient.  Nor  is  there  any 
emergency  in  which  so  much  depends  upon  the  care  and  skill  of 
the  physician.  The  occurrence  of  haemorrhage  at  all  may  generally 
be  prevented  by  a  careful  and  correct  management  of  the  third 
stage  of  labour.  When  haemorrhage  does  occur,  the  life  of  the 
patient  will  generally  depend  upon  the  promptitude  and  vigour  of 
the  treatment. 

Frequency. — The  frequency  of  post-partum  haemorrhage  varies 
so  much,  both  according  to  the  circumstances  and  social  position  of 

62—2 


980  The  Practice  of   Midwifery. 

the  patients  and  the  skill  of  the  accoucheur,  that  no  estimate  can 
be  given.  In  the  Guy's  Hospital  Charity  (1863 — 1875)  fatal  cases 
were  in  the  proportion  of  1  in  2,040  deliveries,  and  formed  about 
10  per  cent,  of  the  total  mortality  after  delivery.  Deaths  due  to 
post-jMrtum  slightly  exceeded  in  number  those  due  to  ante-partum 
haemorrhage.  The  frequency  of  post-partum  haemorrhage  in  this 
Charity  is  probably  much  greater  than  the  general  average,  for  the 
patients  are  often  very  ill-nourished  and  frequently  are  late  in 
sending  for  assistance,  so  that  the  child  is  often  born  before  the 
attendant  arrives. 

In  the  University  College  Hospital  Maternity  Department  from 
1893  to  1900  in  15,130  confinements  39  women,  or  1  in  387,  suffered 
from  considerable  post-partum  haemorrhage.  In  8  instances  the 
patient's  life  was  endangered,  2  of  these  cases  ending  fatally,  a 
mortality  of  1  in  7,565  deliveries.  Veit^  among  47,065  deliveries 
found  5  deaths  from  atonic  post-partum  haemorrhage,  a  proportion 
of  1  in  10,189. 

Normal  Mechanism  for  controlling  Hsemorrhage. — The 
numerous  large  arteries  and  veins  entering  the  placenta  are  torn 
across  on  separation  of  the  placenta  through  the  shrinking  of  the 
uterus,  and  the  blood  which  follows  the  birth  of  the  child  comes 
from  these  vessels.  The  arrest  of  bleeding  depends  upon  the 
compression  of  the  vessels  by  the  contraction  of  the  uterus.  This 
is  facilitated  by  the  anatomical  arrangements  already  described 
(see  p.  103),  namely,  the  spiral  course  of  the  arteries  and  the 
so-called  "falciform  valves"  in  the  venous  sinuses.  The  veins, 
however,  are  destitute  of  true  valves,  and  thus,  in  the  absence  of 
contraction,  blood  may  pour  in  great  volume  from  the  veins  as  well 
as  from  large  arteries.  Fatal  haemorrhage  may  thus  occur  in  a  few 
minutes. 

Besides  the  contraction  of  the  uterus,  a  part  of  importance  is 
also  played  by  retraction,  that  is  to  say,  by  the  reduction  of  its 
size  and  thickening  of  its  walls,  not  followed  by  relaxation  and 
expansion.  The  more  complete  is  the  retraction  the  more 
thoroughly  are  the  vessels  closed  and  blood  squeezed  out  of  the 
large  venous  sinuses.  Hence  the  security  against  haemorrhage  is 
greater  after  the  delivery  of  the  placenta  than  before. 

After  delivery,  as  at  other  times,  uterine  contractions  only  take 
place  rhythmically  at  intervals.  It  is  only  during  a  contraction 
that  the  well-known  hard,  defined,  cricket-ball-like  outline  of  the 
uterus  is  felt  which  assures  the  physician  of  the  impossibility  of 

1  Veit,  Zeitschr.  f.  Geburt.  u.  Gyniik.,  1894,  Bd.  28,  s.  210. 


Retention  of  the  Placenta,   Etc.  981 

hsemorrhage  from  the  placental  site  for  the  time  being.  But,  even 
during  the  intervals,  although  the  uterus  becomes  softer,  a  suffi- 
cient amount  of  tonic  contraction  normally  remains  to  prevent  the 
vessels  becoming  patent  again.  The  uterus  should  not  become 
larger  during  the  intervals  of  contraction.  A  further  security 
against  haemorrhage  is  afforded  by  the  thrombi  which  form  in  the 
vessels,  but  it  is  unknown  how  soon  these  are  normally  produced. 
Owing  to  the-  presence  of  these,  even  a  morbid  relaxation  of  the 
uterus  at  a  considerable  interval  after  the  delivery  of  the  child  is 
not  necessarily  accompanied  by  haemorrhage. 

Causation  of  Haemorrhage. — The  one  essential  cause  of 
haemorrhage  from  the  placental  site  is  atony  of  the  uterus,  and 
without  this  it  can  never  occur.  The  atony  does  niDt  necessarily 
affect  the  whole  uterus,  but  haemorrhage  may  occur  with  irregular 
contraction,  some  part  of  the  uterus  being  contracted  and  some 
relaxed.  In  this  case  it  is  essential  that  the  placental  site,  or  part 
of  it,  should  be  the  atonic  portion,  as  it  is  generally  apt  to  be.  If 
the  whole  uterus  is  relaxed  it  may  allow  itself  to  be  dilated  again 
to  a  considerable  size  by  the  blood  poured  out  into  it.  Given  a 
certain  amount  of  uterine  atony,  there  are  other  causes  which 
promote  haemorrhage.  The  first  of  these  is  imperfect  uterine  retrac- 
tion. This  may  be  due  to  the  placenta  being  still  within  the  uterus, 
especially  when  partially  adherent ;  to  the  presence  of  clots  within 
the  uterus,  distending  its  cavity ;  to  a  fibroid  tumour  in  its  walls ; 
or  to  the  presence  of  adhesions  to  some  other  structure  which 
prevent  due  retraction.  In  102  cases  of  labour  following  ventrofixa- 
tion of  the  uterus  Negri  ^  records  5  cases  of  post-partum  haemorrhage, 
a  proportion  much  above  the  average.  Other  causes  promoting 
haemorrhage  are  excessive  vascular  tension,  arterial  or  venous,  excited 
action  of  the  heart,  relaxation  of  the  arteries  supplying  the  uterus, 
and  any  condition  of  the  blood  rendering  it  less  prone  to  form 
thrombi,  as  in  cases  of  septic  infection  or  haemophilia.^  In  those 
women  who  show  a  special  proneness  to  flooding  in  successive 
deliveries  it  is  probable  that  some  of  these  causes  are  often  in 
operation,  as  well  as  a  tendency  to  uterine  inertia.  Too  early 
assuming  the  erect  posture  may  also  promote  haemorrhage,  by 
increasing  the  statical  pressure  in  the  vessels  and  exciting  the 
circulation. 

Causation  of  Uteriiie  Atony. — The  constitutional  causes  of  uterine 
atony  after  delivery  are  similar  to  those  which  produce  inertia  in 

1  Negri,  Annali  di  Ostelricia  e  Ginecologia,  August,  1890. 

2  Kehrer,  Archiv  f.  Gyntik.,  1876,  lid.  10,  s.  201. 


982  The  Practice  of   Midwifery. 

labour,  and  hence,  when  there  has  been  marked  mertia  in  labour, 
the  physician  should  be  on  his  guard  against  post-partum  hsemor- 
rhage.  Any  debilitated  condition  or  any  form  of  malnutrition  may 
be  a  cause  of  inertia.  The  great  danger  of  even  a  slight  degree  of 
post-partum  haemorrhage  when  ante-partum  haemorrhage  has 
occurred  is  well  known.  Certain  women  have  a  constitutional 
proclivity  to  flooding,  not  easily  explained,  and  have  been  described 
as  '*  flooders."  This  proclivity  may  depend  upon  some  morbid 
state  of  the  nervous  system,  since  the  uterine  contraction  is  directly 
regulated  by  the  nerves.  A  diseased  state  of  the  "  ganglion  cervi- 
cale  uteri  "  has  been  assigned  as  one  possible  cause.^  To  these 
constitutional  causes  must  be  added  exhaustion  from  protracted 
labour,  frequent  child-bearing,  previous  over-distension  of  the 
uterus,  as  from  twins  or  excessive  liquor  amnii,  and  the  administra- 
tion of  chloroform.  Westermark^  has  shown  that  chloroform  when 
given  to  the  obstetrical  degree  lengthens  the  intervals  between  the 
pains,  diminishes  their  frequency,  and  causes  the  individual  con- 
tractions to  begin  more  suddenly  and  to  pass  off  more  rapidly. 
Too  rapid  artificial  delivery  while  the  uterus  is  quiescent,  and  in 
a  condition  of  secondary  inertia,  the  temporary  passiveness  of 
Braxton  Hicks,  may  also  be  a  cause.  Spontaneous  precipitate 
labour  is  also  described  as  likely  to  be  followed  by  haemorrhage,  but 
this  tendency  appears  to  have  been  exaggerated.  Fritsch  has  called 
attention  to  cases  of  uterine  atony  due  to  septic  infection  occurring 
during  labour,  the  paralysis  of  the  uterine  muscle  being  analogous 
to  that  of  the  intestinal  muscle  seen  so  commonly  in  cases  of 
septicEemia. 

Extreme  nervous  depression  and  shock,  such  as  may  follow  the 
birth  of  a  still-born  child,  may  account  for  the  uterine  inertia  in  some 
cases.  In  a  large  proportion  of  cases  the  relaxation  of  the  uterus 
which  allows  the  haemorrhage  occurs  when  for  some  reason  the 
physician  has  omitted  to  keep  a  constant  watch  on  the  condition 
of  the  uterus  by  keeping  his  hand  upon  it  continuously  until  the 
placenta  has  been  delivered,  and  he  is  assured  that  a  satisfactory 
and  permanent  uterine  contraction  has  been  obtained.  Some  of 
the  worst  cases  have  happened  when  attention  has  been  diverted 
by  the  necessity  for  resuscitating  the  child,  or  when  the  child  has 
been  born  before  the  arrival  of  the  physician. 

Symptoms  and  Diagnosis. — The  haemorrhage  may  occur 
immediately   after  the   birth   of   the    child,   or,   after    remaining 

1  Jastreboff,  Trans.  Obst.  Soc.  London,  1881,  Vol.  XXIII.,  p.  273. 

2  Westermark,  Paris  Thesis,  1878. 


Retention  of  the  Placenta,    Etc.  983 

contracted  at  first,  the  uterus  may  relax  again  and  allow  haemorrhage 
either  before  or  after  the  delivery  of  the  placenta.  At  first  the 
blood  is  poured  out  into  the  flaccid  uterus.  After  a  while  a  con- 
traction may  occur  and  expel  it  in  a  copious  stream ;  or  the  same 
effect  may  be  produced  by  the  patient's  coughing  or  bearing  down, 
or  the  pressure  of  the  hand  upon  the  fundus.  The  quantity  may  be 
so  great  as  to  drench  the  bed,  and  even  pour  abundantly  on  to  the 
floor.  Even  without  external  flow  the  uterus  may  allow  itself  to 
be  expanded  again  so  much  that  dangerous  and  even  fatal  haemor- 
rhage may  take  place  into  its  interior,  "concealed  post-partum 
haemorrhage."  The  physician  can  only  be  certain  that  no  excess 
of  haemorrhage  is  going  on  by  keeping  his  hand  for  a  sufficient  time 
upon  the  uterus,  making  sure  that  it  does  not  altogether  lose  its 
definite  outline  or  become  enlarged  in  the  interval  of  contractions, 
and  that  no  copious  gush  of  blood  from  the  vagina  is  produced  by 
a  pain  or  by  pressure  upon  the  fundus.  If  haemorrhage  occurs 
without  even  temporary  relaxation  of  the  uterus,  it  must  be  due  to 
some  other  source  of  bleeding,  such  as  laceration  of  uterus,  cervix, 
vagina,  or  vulva,  and  careful  search  must  be  made  for  the  source. 
It  has  even  been  known  that  a  patient  has  bled  to  death  from  a 
ruptured  varicose  vein  in  the  leg,  while  the  accoucheur  was  directing 
his  attention  to  the  uterus. 

A  copious  haemorrhage  may  be  quickly  followed  by  syncope, 
which  is  in  some  cases  an  advantage,  since  it  checks  the  flow  of 
arterial  blood.  Otherwise,  in  severe  cases,  the  pulse  becomes 
rapid  and  weak,  or  even  imperceptible ;  there  is  extreme  pallor  of 
the  face,  lips  and  gums,  the  patient  is  bathed  in  cold  sweat,  she 
gasps  for  breath,  for  lack  of  sufficient  blood  corpuscles  to  carry 
on  respiration  properly,  and  tosses  her  limbs  about  restlessly. 
Towards  the  last  she  complains  of  being  unable  to  see.  Voice  and 
even  muscular  strength  may  apparently  remain  good  almost  to  the 
end.  The  gravest  signs  of  impending  death  are  absolute  failure  of 
pulse,  extreme  restlessness,  and  failure  of  sight. 

Prophylaxis. — In  the  great  majority  of  cases,  haemorrhage  may 
be  averted  by  due  care,  although,  very  exceptionally,  women  are 
found  in  whom  flooding  takes  place  notwithstanding  the  utmost 
precautions.  But  practitioners  who  manage  labour  properly  will 
never  find  post-partum  haemorrhage  anything  but  a  rare 
occurrence. 

If  women  are  known  to  be  liable  to  flooding  they  should  be 
treated  if  possible  during  pregnancy  by  tonics,  especially  iron, 
iron  and  quinine,  or  small  doses  of  ergot  and  strychnine  combined 


984  The  Practice  of   Midwifery. 

with  iron,  as  well  as  by  good  diet  and  other  hygienic  means. 
Women  with  a  history  of  haemophilia  should  be  given  calcium 
chloride  in  ten  grain  doses  three  times  a  day  for  the  last  three  or 
four  weeks  of  their  pregnancy.  In  women  with  a  history  of 
previous  haemorrhage,  a  dose  of  ergot  may  be  given  just  as  the 
head  is  reaching  the  perineum,  if  it  is  certain  that  no  obstruction 
exists.  The  same  treatment  may  also  be  adopted  in  multiparae 
when  inertia  of  the  uterus  has  been  very  marked  throughout  labour. 
Chloroform  should  be  avoided,  as  far  as  possible,  in  the  case 
of  women  prone  to  haemorrhage.  When  chloroform  is  given  to 
the  full  degree,  as  for  obstetric  operations,  anaesthesia  should  not 
be  deep  at  the  final  state  of  delivery,  and  the  uterus  should  not 
be  emptied  too  quickly,  but  allowed  to  expel  (in  head  presentations) 
the  body  of  the  child.  The  most  important  part  of  all  in  the 
prophylaxis  of  haemorrhage  is  that  the  physician  should  manage 
the  third  stage  of  labour  correctly  according  to  the  principles 
already  described,  following  down  the  fundus  uteri  with  his  hand 
at  the  expulsion  of  the  child,  and  keeping  a  watch  upon  the  uterus 
until  the  placenta  is  expelled,  and  permanent  contraction  is 
secured.  While  engaged  in  tying  the  funis,  or  resuscitating  an 
asphyxiated  foetus,  he  should  direct  the  nurse  or  other  assistant  to 
keep  up  pressure  upon  the  fundus. 

Ergot  is  useful  rather  as  a  prophylactic,  or  to  prevent  recur- 
rence, than  in  the  presence  of  severe  haemorrhage,  for  there  is 
then  no  time  for  it  to  act.  If  it  is  found  difficult,  after  removal 
of  the  placenta,  to  maintain  a  sufficiently  firm  condition  of  the 
uterus,  or  if  gushes  of  blood  take  place  whenever  the  uterus 
hardens,  ergot  should  be  given.  The  most  rapid  method  is  to 
inject  two  grains  or  more  of  ergotin  or  5  to  10  minims  of  ernutin 
deeply  into  the  gluteal  muscles.  In  the  absence  of  these  prepara- 
tions, a  drachm  dose  of  the  liquid  extract  of  ergot  may  be  given,  and 
repeated,  if  necessary,  or  a  fresh  infusion  may  be  made  of  sixty 
grains  of  powdered  ergot,  and  the  powder  and  infusion  administered 
together.  The  liquid  extract,  diluted  with  an  equal  part  of  water, 
may  also  be  used  hypodermically.  A  wineglassful  of  vinegar,  taken 
by  the  mouth,  has  sometimes  been  found  to  check  haemorrhage 
rapidly.  It  may  probably  cause  a  reflex  effect  upon  the  uterus. 
In  any  case  in  which  flooding  is  anticipated,  a  hypodermic  syringe 
should  be  ready,  filled  with  a  solution  of  ergotin  or  ernutin,  and 
iodoform  gauze  for  plugging  the  uterus  should  also  be  prepared. 
In  all  cases  hot  water  should  be  at  hand. 

It  has  been  observed  that  a  probability  of  haemorrhage  is  indicated 
if  the  pulse  remains  rapid  after  delivery,  instead  of  falling  to  a 


Retention   of  the  Placenta,    Etc.  985 

quiet  rate.  Whenever  this  condition  is  observed,  therefore,  the 
condition  of  the  uterus  should  be  watched  for  a  longer  time  than 
usual,  and  a  dose  of  ergot  may  be  given  with  advantage. 

Treatment.— The  essential  point  in  treatment  is  to  secure 
contraction  of  the  uterus,  and  by  far  the  greater  part  of  the  value 
of  all  the  means  used  for  the  arrest  of  haemorrhage  consists  in 
their  efficacy  in  producing  this  effect.  The  first  expedient  to  be 
tried  is  that  of  direct  manual  stimulation  to  the  uterus.  The 
patient  should  be  placed  on  her  back,  and  the  uterus  grasped, 
compressed,  and  kneaded  with  both  hands.  Care  must  be  taken 
not  to  cause  inversion  of  the  relaxed  uterus  by  pressing  downward 
one  part  of  the  fundus.  If  this  treatment  does  not  quickly  succeed 
in  producing  hardening  and  contraction,  one  hand  should  be  intro- 
duced into  the  uterus,  all  clots  turned  out,  and  the  placenta 
removed,  if  it  has  no'"  previously  been  expelled.  The  uterine  walls 
are  then  compressed  between  the  outside  hand  and  that  in  the 
uterine  cavity,  the  latter  affording  an  additional  stimulus  to  con- 
traction. If  the  placenta  has  been  exjDelled,  the  uterine  walls 
should  be  examined,  while  in  a  state  of  contraction,  to  make  sure 
that  no  portion  of  placenta  or  membranes  remains  attached. 
"When  this  has  been  done,  and  fair  contraction  secured,  the  hand 
should  be  slowly  withdrawn  into  the  vagina,  and  the  fingers 
placed  in  the  posterior  cul-de-sac,  so  that  the  cervix  is  received  in 
the  hollow  of  the  hand.  The  fundus  is  then  drawn  forward  toward 
the  pubes  in  the  grasp  of  the  external  hand,  and  the  uterus  com- 
pressed in  the  direction  of  its  axis  until  retraction  is  secured,  and 
the  cavity  closed. 

If  bimanual  comiDression  does  not  produce  adequate  contraction, 
or  if  relaxation  and  haemorrhage  recur,  stimulation  by  heat  should 
be  tried. 

Intra-uterine  injection  of  hot  water  is  the  most  valuable  means  of 
exciting  uterine  contraction.  A  large  jugful  of  water  should  be 
ready,  and  the  temperature  should  be  from  115°  F.  to  120°  F.,  or 
the  water  may  be  used  as  hot  as  the  hand  can  bear.  The  patient's 
hips  may  be  brought  over  the  edge  of  the  bed  in  the  lateral  position, 
and  a  mackintosh  arranged  to  convey  the  water  to  a  footpan  below. 
A  long  tube  should  be  used  which  can  be  passed  up  to  the  fundus 
uteri,  and  has  a  curve  corresponding  to  that  of  the  genital  canal, 
either  a  metal  tube  such  as  Budin's,  or  one  of  vulcanite  or  glass. 
In  the  absence  of  a  special  tu)>e,  the  ordinary  tube  of  an  irrigator 
can  be  used,  but  it  will  be  necessary  to  pass  the  vaginal  tul^e  wholly 
into  the  uterus.     The  water  is  then  to  be  injected  in  considerable 


986 


The  Practice  of   Midwifery. 


quantity,  several  quarts  at  least,  until  contraction  is  produced,  great 
care  being  taken  to  avoid  the  injection  of  air.  If  a  Higginson's 
syringe  has  to  be  used  in  the  absence  of  an  irrigator,  special  care 
must  be  taken  to  avoid  the  entry  of  air. 

If  bimanual  compression  and  the  use  of  a  hot  douche  both  fail  to 
arrest  the  bleeding — and  this  will  very  seldom  occur  if  they  are 
employed  properly — then,  as  a  last  resource,  the  uterus  should  be 
plugged.  There  are,  however,  two  classes  of  cases  in  which  this 
method  may  be  necessary  in  preference  to  either  of  the  others, — 

namely,  when  the  uterus  is 
prevented  from  contracting 
and  retracting  by  the  presence 
of  adhesions  or  the  existence  of 
fibroid  tumours  in  its  walls. 
Sohauta  has  suggested  that,  in 
some  very  severe  cases  of  post- 
partum haemorrhage,  the 
uterine  vessels  may  be  athero- 
matous, and  in  any  case  where 
this  condition  is  suspected  gauze 
plugging  should  be  carried  out. 
Schmit  ^  has  recorded  a  case  of 
this  kind  in  which  the  patient 
died  of  uncontrollable  hsemor- 
rhage,  although  after  plugging 
had  failed  the  uterus  was  ulti- 
mately removed  in  an  endeavour 
to  arrest  the  bleeding.  On 
microscopic  examination  well- 
marked  hyaline  degeneration 
of  the  vessels  at  the  placental 
site  was  found. 
The  best  material  for  plugging  is  iodoform  or  sterilised  gauze  in 
long  and  rather  broad  strips.  In  the  absence  of  this,  muslin,  lint, 
strips  cut  from  a  clean  sheet,  or  any  available  material,  may  be  used, 
and  should  be  sterilised  by  boiling  water  or  wrung  out  of  a  weak 
antiseptic  lotion.  Plugging  the  uterus  may  be  carried  out  in  the 
following  way.  The  uterus  is  drawn  down  to  the  vulva,  a  manoeuvre 
which  has  the  advantage  of  assisting  to  arrest  the  bleeding,  or 
pushed  down  through  the  abdomen.  The  gloved  left  hand  is  then 
introduced  up  to  the  fundus  and  all  blood  clot  or  fragments   of 


Fig.  482. — Uterus  and  vagina  completely 
and  properly  plugged  with  gauze. 
(Bumm.) 


1  Schmit,  Zentralbl.  f.  Gyniik.,  1899,  no.  35,  s.  1089. 


Retention  of  the   Placenta.   Etc. 


987 


placenta  removed.  The  strips  of  iodoform  gauze  or  any  other 
available  material  are  then  passed  up  to  the  fundus  with  a  pair 
of  uterine  dressing  forceps  and  the  fingers  of  the  left  hand,  and  the 
whole  uterine  cavity  firmly  and  completely  packed  from  above 
down.  Special  care  must  be  taken  that  no  space  in  which  blood 
might  accumulate  is  left  between  the  fundus  and  the  gauze.  The 
vagina  should  also  be  packed,  a  large  pad  of  wool  placed  over  the 
vulva,  and  then  a  binder  and  T  bandage  applied  with  considerable 


Fig.  483. — A  uterus  and  vagina  improperly  plugged  with  gauze.  The  gauze 
fills  only  the  lower  uterine  segment  and  the  vagina.  A  portion  of 
retained  placenta  is  seen  at  the  fundus.     (Bumm.) 

pressure.  The  plug  should  be  taken  out  at  the  end  of  eighteen  to 
twenty-four  hours,  and  the  uterus  douched  out.  If  any  hsemorrhage 
recurs  the  plug  must  be  removed,  the  uterus  washed  out  with  a  hot 
douche  and  if  necessary  replugged. 

Diihrssen  -^  records  65  cases  of  post-partum  haemorrhage  treated 
by  the  uterine  plug,  with  6  deaths,  of  which  1  only  was  from 
septicemia. 

Treatment  of  resulting  Ancemia. — In  slight  cases  of  haemorrhage 
it  is  sufficient  to  give  liquid  nourishment  as  soon  as  possible. 
Beef-tea  or  fluid  meat,  with  plenty  of  salt,  answers  well,   since  it 

1  Volkmann,  Bammlung  Klinischc  Vortriige,  1890,  no.  347  (Gyn.  no.  100). 


988  The  Practice  of   Midwifery. 

allows  water  and  saline  constituents  to  be  absorbed  quickly  and 
replenish  the  volume  of  the  blood.  It  is  well  also  to  give  a  dose 
of  opium  or  subcutaneous  injection  of  morphia,  in  order  to  quiet  the 
circulation,  and  relieve  the  nervous  irritability  which  results  from 
haemorrhage. 

In  graver  cases,  in  which  there  is  temporary  syncope,  failure  of 
pulse,  extreme  pallor.,  vomiting,  or  great  restlessness,  the  chief 
indication  is  to  maintain  the  action  of  the  heart  and  avert  fatal 
syncope.  In  the  great  majority  of  cases  of  j)ost-partum  haemor- 
rhage the  patients  recover  if  they  do  not  die  from  syncope  within 
an  hour  or  two.  Sometimes,  however,  it  appears  that  not  enough 
blood-corpuscles  are  left  to  permanently  carry  on  respiration  or 
maintain  the  nutrition  of  the  heart.  Then,  although  the  pulse 
may  improve  for  a  time,  it  fails  again,  and  the  patient  dies  after  a 
considerable  number  of  hours.  This  result  is  more  likely  if  there 
has  been  ante-partum  haemorrhage,  for  then  the  loss  is  generally 
more  gradual,  and  a  patient  may  be  more  completely  drained  of 
blood  without  the  immediate  production  of  fatal  syncope. 

The  first  j)oint  is  to  counteract  anaemia  of  the  brain  by  lowering  the 
head.  All  pillows  should  be  taken  away,  and  the  head  should  not 
be  raised  at  all  for  any  purpose,  such  as  the  giving  of  nourishment, 
till  it  is  certain  that  all  danger  has  passed  away.  It  is  useful  also 
to  raise  the  foot  of  the  bed  upon  blocks,  so  that  the  head  may  be 
lower  than  the  body.  Alcohol  should  be  avoided  until  the  haemor- 
rhage is  arrested.  When  that  is  done,  brandy  may  be  given  if  the 
patient  is  not  sick.  If  she  is  sick,  or  if  brandy  does  not  suffice 
to  revive  the  pulse,  subcutaneous  injections  of  ether,  n\  10,  or 
strychnine,  ^  gr.,  should  be  given  and  repeated  as  required.  In 
the  absence  of  ether,  brandy  may  also  be  injected  subcutaneously. 

Auto-transfusion. — If  the  pulse  still  indicates  danger,  notwith- 
standing the  use  of  stimulants,  there  is  a  valuable  resource  in  a 
method  which  has  been  called  auto-transfusion.  This  consists  in 
bandaging  the  limbs,  so  as  to  save  a  larger  proportion  of  the 
blood  to  fill  the  heart  and  vessels  of  the  brain.  The  legs  should  be 
bandaged  from  the  feet  to  the  hips.  Esmarch's  elastic  bandage  is 
the  most  effective,  but,  in  its  absence,  a  calico  bandage,  firmly 
ajDplied,  may  be  used.  The  arms  may  also  be  bandaged  in  the  same 
way.  The  bandages  may  be  allowed  to  remain  for  some  hours, 
until  the  patient  has  been  able  to  retain  nourishment  and  the  pulse 
has  revived. 

Intra-venous  Injection  of  Saline  Fluid. — The  plan  of  injecting  a 
saline  solution  into  the  veins  is  the  best  method  of  treating 
extreme  cases  of  haemorrhage.     Such  injections  tend  to  counteract 


Retention  of  the  Placenta,   Etc. 


989 


the  tendency  to  fatal  syncope  resulting  from  emptiness  of  the 
vessels,  but  not  the  failure  of  respiration  or  of  the  nutrition  of 
the  heart  from  lack  of  blood.  They  are  probably  useless  when 
the  patient  fails  again  after  being  at  first  revived  by  stimulants, 
and  after  being  able  to  absorb  fluid  from  the  stomach.  Even  when 
used  at  the  early  stage  they  have,  in  some  cases,  proved  to  be  of 
temporary  benefit  only.  Intra-venous  injections  are  now  much 
practised  for  the  haemorrhage  and  collapse  of  ordinary  surgical  opera- 
tions, and  have  been  found  to  have  a  powerful  effect  in  improving 


Fig.  484. — Horrocks'  apparatus  for  intra-venous  injection. 

the  pulse  and  rallying  the  patient  from  the  collapsed  condition.  The 
modern  plan  is  to  inject  in  all  cases  a  considerable  quantity  of  the 
fluid,  as  much  as  from  four  to  six  pints.  The  saline  used  may  be 
common  salt,  or  two  parts  of  salt  mixed  with  one  part  of  bicar- 
bonate of  soda.  About  90  grains  of  the  mixture  may  be  dissolved 
in  each  pint  of  hot  water,  which  should  have  been  sterilised  by 
boiling,  if  time  allows.  It  is  best,  whenever  possible,  to  use  the 
tabloids,  which  are  now  prepared  for  this  purpose,  containing 
potassium,  sodium,  and  calcium  chloride  with  a  small  quantity  of 
bicarbonate  of  soda  and  dextrose.  The  solution  should  be  strained 
through  muslin  or  filtered,  and  injected  at  a  temperature  of  about 


990  The  Practice  of    Midwifery. 

100°  F.  A  funnel  with  tube  and  cannula  is  the  best  apparatus  to 
use,  or  a  large  glass  syringe,  with  the  piston  removed,  answers  very- 
well  the  purpose  of  a  funnel. 

In  Fig.  484  is  shown  the  mode  of  using  an  apj)aratus  devised  by 
Dr.  Horrocks  for  intra-venous  injection  of  fluid.  In  this  case,  the 
cannula  has  a  small  round,  not  a  bevelled  opening ;  and  has  to  be 
tied  into  the  vein. 

Injection  of  saline  fluid  should  be  practised  in  all  cases  in 
which  the  pulse  becomes  very  bad  from  the  immediate  effects  of 
hfemorrhage,  as  soon  as  the  bleeding  has  been  arrested.  If  the 
collapse  recurs  after  this,  after  an  interval  of  some  hours,  and 
stimulants  fail,  probably  the  only  chance  of  saving  the  patient  is 
transfusion  of  blood. 

An  equally  good  effect  has  been  claimed  for  the  plan  of  injecting 
a  saline  fluid  into  the  cellular  tissue.  A  special  apparatus  has 
been  invented  for  this,  but  one  can  be  improvised  with  a  piece  of 
drainage  tube  four  or  five  feet  long,  a  large  funnel,  and  an  aspirator 
needle.  The  funnel  is  fixed  at  one  end  of  the  tube,  and  the  needle 
at  the  other.  The  tube  having  first  been  filled,  the  needle  is 
inserted  at  the  edge  of  the  breast  or  into  the  axilla,  and  the  fluid  is 
allowed  to  flow  by  gravity,  the  funnel  being  kept  filled.  When 
symptoms  are  urgent,  this  method  is  not  so  good  as  intra-venous 
injection,  since  it  does  not  so  rapidly  raise  the  vascular  pressure. 

After-treatment. — After  transfusion,  or  in  cases  of  haemorrhage 
of  severity  just  short  of  that  demanding  transfusion,  great  care 
is  necessary  in  giving  fluid  nourishment  frequently  and  in  very 
small  quantities,  in  order  to  secure,  if  possible,  its  retention  and 
absorption.  At  first,  not  more  than  a  tablespoonful  should  be  given 
at  a  time.  Fluid  meat  or  beef-tea  may  be  given  at  first,  milk  or 
gruel  a  little  later,  brandy  being  added  if  the  pulse  flags.  The 
head  must  be  kept  low  until  all  danger  of  syncoi3e  has  passed. 

Secondary  Puerperal  Haemorrhage. — Secondary  puerperal 
haemorrhage  may  occur  at  any  time  within  the  puerperal  period, 
sometimes  even  several  weeks  after  delivery.  The  bleeding  may 
be  caused  by  detachment  of  thrombi  from  the  vessels  at  the 
placental  site,  or  the  blood  may  come  from  other  parts  of  the 
mucous  membrane.  The  haemorrhage  may  take  the  form  of 
excessive  lochial  discharge,  or  a  profuse  loss  may  come  on 
unexpectedly. 

Causation. — Haemorrhage  may  arise  from  any  cause  producing 
active  or  passive  congestion  of  the  uterus.  Among  these  are  over- 
exertion, getting  up  too  early,  mental  excitement,  inversion  of  the 


Retention  of  the   Placenta,    Etc.  991 

uterus,  laceration  of  the  cervix,  retroflexion  of  the  uterus,  retention 
of  clots  within  the  uterus,  sometimes  merely  a  relaxed  condition 
of  uterus,  or  softened  congested  state  of  the  mucous  membrane. 
The  most  important  cause  of  all  is  the  retention  of  a  piece  of 
adherent  placenta  or  membranes.  This  cause  should  be  suspected 
as  probable  if,  after  a  normal  lochial  discharge  at  first,  a  profuse 
loss  comes  on  after  ten  or  fourteen  days.  Constitutional  con- 
ditions, such  as  albuminuria,  may  also  predispose  to  secondary 
haemorrhage. 

Treatment. — A  vaginal  examination  should  always  be  made,  and 
if  the  cervix  still  admits  the  finger,  and  the  loss  is  considerable, 
the  uterine  cavity  should  be  explored.  If  the  cervix  is  found 
closed,  and  the  loss  not  excessive,  the  patient  should  be  kept 
perfectly  at  rest,  and  styptics,  such  as  the  liquid  extract  of  ergot 
in  half-drachm  or  drachm  doses,  or  tincture  of  cannabis  indica  in 
fifteen-minim  doses,  should  be  administered.  Any  retroflexion  of 
the  uterus  should  be  rectified  by  a  pessary. 

If  this  treatment  fails  to  arrest  the  loss,  or  if  the  bleeding  is 
excessive,  the  interior  of  the  uterus  should  be  explored,  the  cervix 
being  first  dilated  by  Hegar's  dilators  or  a  tent  if  necessary.  If 
involution  has  proceeded  to  a  considerable  extent,  it  will  be  possible 
to  reach  the  fundus  without  introducing  more  than  the  index  finger 
into  the  vagina,  as  in  the  case  of  an  abortion  (see  p.  582). 
If  the  uterus  is  still  large,  it  will  be  necessary  to  pass  the  half- 
hand  or  whole  hand  into  the  vagina.  For  this  purpose,  an  anaes- 
thetic should  be  administered.  If  any  placenta  or  membrane  is 
found  within,  it  must  be  carefully  broken  down  by  the  finger  and 
removed.  This  will  generally  suffice  to  arrest  the  haemorrhage.  If 
only  a  softened,  congested  state  of  mucous  membrane  is  found, 
the  uterus  should  be  curetted,  and  then  swabbed  out  with  liquor 
iodi  fort,  or  Churchill's  tincture  of  iodine  ^  by  means  of  a  Playfair's 
probe  or  uterine  sound  wrapped  in  absorbent  cotton.  If  only  a 
short  time  has  elapsed  since  delivery,  the  uterine  cavity  may  be 
X)lugged  after  the  curetting  with  iodoform  gauze,  without  any  other 
application. 

1  Iodine,  73  grains  ;  iodide  of  potassium,  90  grains  ;  absolute  alcohol,  1  oz. 


Chapter   XXXIX. 
PUERPERAL  FEVERS. 

The  nature  of  the  disease  known  as  puerperal  fever  has  been 
the  subject  of  much  controversy.  The  view  that  it  is  a  specific 
zymotic  disease,  analogous  to  small-pox  or  scarlatina,  but  liable 
only  to  affect  puerperal  women,  has  been  generally  abandoned. 
The  modern  view  is  that  the  affections  which  have  been  included 
under  the  title  of  puerperal  fever  or  metria  are  analogous  to  the 
febrile  disturbances  which  may  follow  surgical  wounds,  that  they  are 
in  reality  septicaemia,  or  septic  infection,  and  are  due  to  absorption  at 
some  surface,  either  that  of  the  placental  separation,  or  at  lacera- 
tions of  the  cervix,  vagina,  perineum,  or  vulva.  The  importance 
of  this  subject  is  shown  when  we  remember  that  three-fourths  of 
all  the  deaths  occurring  after  delivery  are  due  to  puerperal  fever, 
and  that  in  the  year  1905  1,743  women  died  in  England  and  Wales 
from  this  complication  of  childbed.^ 

That  puerperal  fever,  in  its  severe  forms,  is  a  highly  contagious 
disease  there  can  be  no  doubt.  This  is  proved  both  by  the  records 
of  lying-in  hospitals  and  by  those  of  private  practice.  In  conse- 
quence of  this  disease  the  death-rate  of  some  lying-in  hospitals 
has,  over  a  considerable  interval,  been  as  high  as  15,  20,  or  even 
30  per  cent.  Thus  in  December,  1842,  in  the  first  obstetric  clinique 
in  the  Vienna  Lying-in  Hospital  75  of  the  239  women  who  were 
confined  during  the  month  died,  a  mortality  of  31*38  per  cent.^ 

In  many  instances  such  hospitals  have  had  to  be  closed  in 
consequence  of  the  prevalence  of  the  disease,  and  in  some,  whenthe 
closing  has  been  too  long  deferred,  almost  every  puerperal  patient  has 
died.  On  the  other  hand,  recent  experience  in  lying-in  hospitals 
has  shown  that,  with  careful  use  of  modern  antiseptic  precautions 
against  the  possibility  of  contagion  being  conveyed,  mortality  may 
be  as  low,  or  lower,  in  lying-in  hospitals  than  in  private  practice. 
The  contagious  character  of  puerperal  fever  is  equally  proved  in 
private  practice  by  the  unfortunate  instances  in  which  a  single 
case  of  the  disease  is  followed  by  a  series  of  severe  or  fatal  cases 

1  Registrar-General's  Eeport  for  1905. 

2  Semmelweis,  Gesammelte  Werke,  Gyory,  1905,  Table  2,  p.  104. 


Puerperal   Fevers.  993 

among  the  patients  attended  by  the  same  person,  a  series  arrested 
only  by  his  entirely  giving  up  midwifery  practice  for  some  time. 

The  chief  arguments  showing  that  puerperal  fever  is  not  a 
specific  zymotic  disease  are  the  following : — (1)  The  symptoms  and 
anatomical  lesions  of  the  disease  have  not  a  special  and  definite 
character  like  those  of  a  sjDecific  zymotic  disease,  but  are  rather 
analogous  to  those  of  septic8eD:iia  or  pysemia  following  surgical 
wounds.  The  micro-organisms  found  are  also  generally  the  same 
as  in  surgical  septicaemia  and  pyaemia.  (2)  A  similar  condition 
following  abortion  in  the  earlier  months  gives  rise  to  a  febrile  dis- 
turbance which  resembles  puerperal  fever,  though  it  generally 
differs  from  it  in  being  less  fatal.  (3)  Puerperal  fever  may  be 
originated  not  merely  by  contagion  conveyed  from  other  puerperal 
women,  but  by  various  kinds  of  septic  material,  notably  by  post- 
mortem poison,  or  contagion  from  erysipelas,  or  suj^purating 
wounds.  The  former  was  specially  demonstrated  by  Semmelweis,^ 
who  showed  that  among  the  patients  in  the  lying-in  hospital  at 
Vienna  attended  by  students  who  at  the  same  time  were  attending 
the  dissecting  and  post-mortem  rooms  the  mortality  was  as  much 
as  10  per  cent.  Among  those  attended  by  women  in  the  same 
institution  it  was  only  3  per  cent.  In  consequence  of  this  evidence 
a  strict  rule  was  enforced  that  the  students  should  wash  their 
hands  with  a  solution  of  chlorinated  lime,^  and  not  merely  with 
soap  and  water,  and  a  great  reduction  of  mortality  was  thereby 
obtained,  namely,  to  about  1  per  cent. 

Organisms  in  Puerperal  Fever. — The  ordinary  bacteria 
which  are  the  chief  agents  in  the  putrefaction  of  organic  fluids  do 
not  live  and  multiply  in  the  tissues.  They  are  present  in  the 
lochial  discharge  as  found  in  the  vagina,  and  doubtless  tend  to 
cause  suppuration  of  the  lacerations  in  the  genital  canal,  which 
would  heal  by  first  intention,  and  without  inflammation,  if  they 
could  be  kept  perfectly  aseptic.  The  lochial  discharge  obtained 
from  the  interior  of  the  uterus  is  said  to  be  normally  sterile.  But 
saprophytic  organisms  frequently  gain  access  to  the  uterus,  and 
cause  the  decomposition  of  any  portions  of  placenta  or  clots 
retained  there.  In  such  case  the  toxins  produced  are  liable  to  be 
absorbed,  and  to  produce  poisonous  effects. 

The  organisms  found  within  the  tissues  in  puerperal  fever  are 
most  frequently  the  micrococci  of  suppuration.  These  are  found 
mingled  with  pus  cells  in  the  cellular  tissue  and  lymphatics. 
They   constitute   a   large   proportion   of   the  diphtheroid  deposits 

1  Hemraelwcis  :  his  Life  and  Doctrine   Sinclair,  l'.)0!>. 
M.  ^3 


994  The  Practice  of   Midwifery. 

sometimes  found  upon  lacerations  of  the  genital  canal.  They  are 
abundant  in  the  purulent  or  semi-purulent  fluid  found  in  the  peri- 
toneal cavity,  and  have  been  seen  also  in  exudations  in  the  pleura, 
pericardium,  and  ventricles  of  the  brain.  They  are  with  difficulty 
discovered  in  the  blood  during  life,  but  they  form  a  large  element 
in  thrombi  in  the  vessels,  and  are  found  in  the  Malpighian  bodies 
of  the  kidneys.     They  have  been  observed  also  in  the  urine. ^ 

Amongst  the  septic  microbes,  Streptococcus  pyogenes  is  most 
often  found,  next  to  that  Staphylococcus  pyogenes  aureus,  but 
Staphylococcus  albus  and  citreus  have  also  been  noted.  Septicaemia, 
therefore,  whether  puerperal  or  not,  is  not  a  pathological  entity 
like  a  zymotic  disease,  but  is  rather  a  group  of  allied  diseases. 
The  Streptococcus  pyogenes,  however,  has  a  greater  power  than 
the  other  cocci  of  penetrating  deeply  into  living  tissues  ;  and  it 
is  so  generally  found,  eitber  alone  or  associated  with  other  cocci, 
that  it  deserves  to  be  regarded  as  the  organism  par  excellence 
of  the  more  severe  and  fatal  forms  of  puerperal  septicaemia. 
Besides  the  cocci,  the  Bacillus  coli  communis  is  capable  of  acting 
as  a  septic  microbe  in  certain  conditions.  When  tbe  vitality  of 
tissues  is  impaired,  and  especially  when  the  intestines  are  also 
distended  from  inbibition  of  peristalsis,  it  appears  to  be  cajDable 
of  penetrating  the  intestinal  wall,  and  multiplying  in  peritoneal 
or  other  effusions,  in  the  neighbourhood  of  intestine.  It  may 
also  readily  be  conveyed  to  the  vagina,  owing  to  the  vicinity  of 
the  rectum,  and  is  frequently  an  agent  in  decomposition  within 
the  uterus,  causing  an  offensive  discharge.  Gebhard^  found  it  in 
seven  cases  of  tympauia  uteri.  When  combined  with  Streptococcus 
pyogenes  it  is  thought  to  render  that  organism  more  virulent.  The 
gonococcus  and  pneumococcus  appear  to  be  also  capable  of  acting 
as  septic  organisms  in  certain  circumstances.  The  gonococcus 
generally  causes  a  mild  form  of  puerperal  infection.  Whitridge 
Williams  has  repeatedly  found  it  in  cases  of  decidual  endometritis. 
The  pneumococcus  has  been  recorded  as  the  agent  in  fatal  septi- 
caemia, sometimes  secondary  to  pneumonia,  sometimes  without  any 
lung  affection.^ 

1  For  observations  on  the  organisms  of  puerperal  fever  and  septicEemia,  see  Bumm, 
Zentralbl.  f.  Gynak.,  1889,  p.  723  ;  Mironow,  ii'j<^.,  1890,  p.  679;  Doderlein,  ilnd.,  1894, 
p.  18  ;  Menge  and  Kronig,  Bakteriologie  des  Weiblichen  Genitalkanales,  Leipzig.  1897  : 
JBumm,  Arch.  f.  Gynak.,  1889,  Bd.  31,  p.  325  :  1891,  Bd.  40,  p.  398  ;  Zeitschr.  f.  Geb! 
und  Gynak.,  189.5,  Bd.  33,  p.  126  ;  Zentralbl.  f.  Gyn.,  1897,  No.  45,  p.  1337;  Eobinson, 
Journ.  Obst.  and  Gyn.,  June,  1902,  Vol.  I.,  p.  646  ;  Foulerton,  ibid.,  May,  1903,  Vol.  III., 
p.  450  ;  Whitridge  Williams,  Obstetrics,  1908,  p.  857  ;  Brieger,  Charite  Annalen,  1888, 
13,  p.  198  ;  Kronig,  Zentralbl.  f.  Gynak.,  1893,  15,  p.  157";  Welch.  Boston  Med.  and 
Surg.  Jour.,  1900,  p.  73  :  Von  Franque,  Zeitschr.  f.  Geb.  u.  Gyn.,  1893,  425,  p.  277. 

2  Verh.  d.  Deutsch.  Gesell.  f.  Gynak.,  1893,  p.  305. 

s  Foulerton  and  Bonney,  Trans.  Obst.  Soc.  London,  1903,  Vol.  XLV.,  p.  128. 


Puerperal   Fevers.  •     995 

In  a  series  of  324  cases  recorded  by  Whitridge  Williams,  in  which 
the  temperature  rose  to  101°  F.  or  higher  within  the  first  ten  days 
of  the  puerperium,  and  in  which  microbes  were  found  in  the  uterine 
lochia,  Streptococcus  pyogenes  was  found  alone  in  60,  or  18'5  per 
cent.,  with  other  organisms  (Bacillus  coli,  Bacillus  aerogenes  capsu- 
latus  and  gonococcus)  in  28,  or  8"6  per  cent. ;  staphylococcus 
alone  in  8,  or  2*4  per  cent. ;  Bacillus  aerogenes  capsulatus  in  3,  or 
0"92  per  cent. ;  Bacillus  coli  alone  in  18,  or  5*5  per  cent. ;  gonococcus 
in  29,  or  8-9  per  cent. ;  various  saprophytic  organisms  in  28,  or  8-6 
per  cent. ;  while  68,  or  20"9  per  cent.,  were  sterile.  In  a  similar 
series  of  179  cases,  examined  by  Kronig,  the  infective  agent  was 
the  Streptococcus  pyogenes  in  75,  or  42  per  cent.,  the  gonococcus  in 
50,  or  27  per  cent. ;  saprophytic  organisms  were  found  in  28 
per  cent. 

It  is  generally  believed  that,  in  the  great  majority  of  cases  at 
any  rate,  the  septic  organisms  (the  gonococcus  excepted)  are  con- 
veyed to  the  vagina  or  uterus  from  without  in  labour  or  the  puer- 
perium. The  vaginal  secretion,  in  the  pregnant  as  in  the  non- 
pregnant condition,  is  adverse  to  the  growth  of  the  cocci  of 
suppuration,  a  condition  which  is  ascribed  to  its  acid  character, 
resulting  from  the  action  of  the  bacillus  of  Doderlein.  Observa- 
tions have  been  very  contradictory  as  to  the  presence  of  streptococci 
and .  staphylococci  in  the  vagina  of  pregnant  women.  But  the 
observations  of  Kronig,  Menge,  and  Whitridge  Williams  tend  to 
show  that,  provided  vaginal  secretion  is  obtained  without  any 
contamination  from  that  of  the  vulva,  neither  Streptococcus 
pyogenes  nor  Staphylococcus  aureus  can  be  cultivated  from  it. 
It  must  be  remembered,  however,  that  the  failure  to  cultivate  a 
particular  organism  in  the  presence  of  many  others  is  not  absolute 
proof  of  its  absence.  If  present  only  in  small  numbers  it  may  be 
missed  in  the  sample  taken,  or  the  incubator  may  be  less  favourable 
for  its  growth  than  the  human  body  in  the  puerperal  state.  Excep- 
tions certainly  occur  in  inflammatory  conditions,  and  I  have  found 
pus  from  the  vagina  to  contain  streptococci  in  abundance,  without 
any  demonstrable  gonococci. 

Kronig^  considers  that  saprophytic  microbes  are  capable  of 
growing  in  tissues  damaged  by  traumatism,  and  in  the  lymph 
canals,  and  quotes  a  fatal  case  of  puerperal  pyrexia  in  which  he 
found  bacteriologically  only  anaerobic  bacteria.  In  43  cases  of 
fever  during  the  puerperium  examined  by  him  he  found  organisms 
not  capable  of  cultivation  in  the  ordinary  media,  and  32  of  these 

1   \eili.  (I.  Duutsch.  Gesel).  f.  Gyniik.,  Wion,  lSi).5,  VI.,  p.  41)8. 

63—2 


996  The  Practice  of   Midwifery. 

were  pure  anaerobic  bacteria.  Aerobic  bacteria  of  decomposition 
are  considered  to  produce  only  a  saprasmia  which  is  generally- 
transient. 

Organisms  in  puerperal  fever,  as  in  other  diseases,  may  produce 
their  effect  in  three  ways :  (1)  by  producing  in  their  growth 
some  substance  which  has  a  poisonous  effect;  (2)  by  consuming 
oxygen  or  other  materials  required  by  the  body ;  and  (3)  by 
forming  j^lugs  which  block  small  vessels  or  lymphatics,  and  produce 
foci  of  local  inflammation,  in  consequence  of  the  toxin  locally  pro- 
duced. It  is  probable  that,  in  most  cases,  all  the  modes  of  action 
are  combined,  the  first  being  the  most  important. 

Varieties  of  Puerperal  Fevers. — Infection  from  decomposed 
or  septic  material  may  occur  either  by  absorption  of  chemical  pro- 
ducts of  decomposition  which  have  a  poisonous  effect,  or  by  the 
entrance  of  organisms  into  the  tissues  or  into  the  blood,  and  their 
multiplication  there.  In  the  first  case,  if  the  source  of  poison  is 
removed,  the  animal  quickly  recovers  from  its  effects,  if  an  almost 
immediately  fatal  dose  has  not  been  absorbed.  In  the  second  case, 
multii^lication  is  likely  to  go  on  notwithstanding  the  removal  of 
the  source  of  infection.  The  body  has,  however,  a  certain  power 
of  resisting  the  growth  of  parasitic  organisms.  In  experiments  on 
animals,  it  has  been  found  that  the  effect  of  sej)tic  fluid  containing 
organisms  injected  into  the  blood  is  generally  transient  unless  the 
quantity  injected  is  considerable.  A  smaller  quantity  injected 
into  the  cellular  tissue  may  j)rove  ultimately  fatal,  since  the 
organisms  multiply  in  the  cellular  tissue,  and  thence  supply  poison 
continuously  to  the  blood  and  lymphatics. 

Saprcemia,  or  Septic  Intoxication  ;  and  SepticcEinia,  or  Septic  Infec- 
tion.— The  most  essential  division  therefore  of  puerperal  fever  is 
into  two  main  classes :  (1)  saprtemia,  or  septic  intoxication,  in 
which  a  chemical  iDoison  only  is  absorbed  ;  (2)  septicaemia,  or  septic 
infection,  in  which  organisms  multiply  in  the  tissues,  or  in  the 
blood,  or  in  both.  The  slightest  degree  of  septic  intoxication  is 
seen  when  wounded  surfaces  suppurate  and  become  inflamed  in 
consequence  of  the  presence  of  the  ordinary  bacteria  of  decompo- 
sition on  the  surface,  not  within  the  tissues.  More  severe  forms 
may  arise  when  foul-smelling  material  is  produced  by  decomposition 
of  retained  placenta  or  clots,  or  of  the  lochial  discharge. 

Septic  organisms  capable  of  multiplying  in  the  tissues  may  be 
derived  from  other  cases  of  puerperal  septicaemia,  septic  discharges 
from  wounds,  surgical  septicemia  or  pyaemia,  post-mortem  poison 
from  autopsies  of  patients  who  have  died  from  diffuse  inflammation 


Puerperal   Fevers.  997 

such  as  peritonitis,  and  zymotic  diseases.  It  is  probable  that 
similar  germs  may  be  casually  present  in  dust,  and  so  may  bo 
conveyed  to  the  genital  canal.  There  may  be  also  special  germs 
present  in  the  air  of  certain  houses  or  localities,  as,  for  instance, 
from  the  effect  of  defective  drains  or  other  insanitary  conditions. 
The  septic  infection  may  be  limited  to  a  special  tract  of  tissue  and 
produce  inflammation  there,  or  the  organisms  may  multiply  in  the 
blood,  and  so  constitute  septicaemia  proper.  When  the  organisms 
not  only  multiply  in  the  blood  and  the  tissues,  but  also  form 
abscesses  in  various  organs  and  parts  of  the  body,  the  condition  is 
called  pyaemia.  In  these  cases  there  is  present  not  only  the 
poisoning  of  the  tissues  with  the  organisms  which  have  established 
themselves  in  the  body,  but  also  the  occurrence  of  septic  emboli,  the 
result  of  suppurative  phlebitis  or  thrombosis.  Pygemia  is  therefore 
not  so  distinct  from  septicaemia  as  septicaemia  is  from  saprsemia. 
It  is  rather  a  later  stage  of  septicaemia,  when  the  disease  is  not 
quickly  fatal. 

The  distinction  between  sapraemia  and  septicaemia  cannot  be 
absolutely  made  by  a  recognition  of  the  microbes  which  produce 
them,  since  the  Bacillus  coli  may  act  as  a  septic  microbe,  and 
anaerobic  saprophytes  are  said  to  multiply  in  necrotic  and  damaged 
tissues.  There  may  be  a  mixture  of  the  two  conditions,  while  one 
or  the  other  preponderates ;  and  sapraemia  may  predispose  to 
sej)tic8emia  by  diminishing  the  resisting  power  of  the  body  both 
locally  and  generally. 

Sapraemia  and  septicaemia  cannot  therefore  always  be  practically 
distinguished.  Sometimes,  indeed,  when  decomposed  material  has 
been  removed  from  the  uterus,  especially  retained  placenta  after 
an  abortion,  febrile  symptoms  disappear  within  a  few  hours,  and 
it  may  then  be  inferred  with  probability  that  nothing  beyond 
sapraemia  existed.  In  general,  if  any  decomposed  material  such 
as  clot  or  placenta  is  found  in  the  genital  canal,  it  may  be  hoped 
that  any  febrile  condition  existing  is  due  to  sapraemia,  and  that  no 
virulent  pathogenic  microbes  have  been  introduced. 

Causation. — The  distinction  of  septicaemia  and  sapraemia  has 
somewhat  superseded  the  old  classification  of  septicaemia  into 
autogenetic  and  heterogenetic  forms,  since  in  all  cases  the 
microbes  must  have  come  originally  from  the  outside.  Yet  a 
valuable  practical  distinction  does  remain  between  cases  in  which 
the  main  cause  is  the  leaving  placenta  or  clot  to  decompose,  or 
lowering  the  vitality  of  the  tissues  by  traumatism,  and  those  in 
which  it  is  the  fresh  introduction  of  septic  germs.     Just  in  the 


998  The  Practice  of   Midwifery. 

same  way  peritonitis  after  abdominal  section  may  result  either 
from  a  quantity  of  blood  being  left  in  the  peritoneal  cavity,  or 
from  virulent  septic  germs  being  conveyed  by  the  surgeon  or 
derived  from  the  locality. 

Streptococci  and  staphylococci  are  commonly  present  at  the 
vulva,  if  not  in  the  vagina.  These  are  acting  as  saprophytes,  and 
appear  to  have  little  or  no  pathogenic  power  under  normal  con- 
ditions. But  the  resisting  power  of  the  vaginal  secretion,  depending 
upon  its  acid  reaction,  is  diminished,  if  not  abolished,  in  the  puer- 
perium,  owing  to  the  alkaline  lochial  discharge;  and  it  may  be 
presumed  that  cocci  from  the  vulva  can  easily  spread  to  the  vagina 
and  uterus  unless  the  vulva  has  been  absolutely  sterilised  and  kept 
sterile.  These  may  be  capable  of  growing  in  damaged,  if  not  in  healthy, 
tissues,  or  of  causing  mild  forms  of  streptococcic  endometritis,  such 
as  still  occur  occasionally  in  lying-in  hospitals,  notwithstanding 
strict  antiseptic  precautions. 

In  very  rare  cases  microbes  may  infect  the  uterus  through  the 
maternal  circulation,  and  even  reach  the  foetus  through  the  placenta. 
Thus  when  the  mother  has  suffered  from  general  infection  by  the- 
Bacillus  coli,  originating  in  a  virulent  appendicitis,  the  foetus  has 
been  found  affected  also.  The  foetus  has  died  within  a  few  hours 
after  birth,  and  has  been  found  to  be  affected  by  a  streptococcic 
pleurisy,  or  pneumonia,  or  endocarditis,  while  the  mother  has 
afterwards  also  shown  signs  of  sepsis. 

Site  of  Absorption. — The  site  of  absorption  may  be  the  uterine 
surface,  especially  the  placental  site,  or  lacerations  of  the  cervix, 
vagina,  vulva,  and  perineum.  Probably  the  main  reason  why 
primiparse  are  so  much  more  liable  to  puerperal  septicaemia  is 
that  in  them  some  laceration  of  the  vaginal  outlet  is  inevitable, 
and  more  extensive  laceration  is  common.  During  and  even  before 
labour,  infection  may  be  conveyed  to  the  cervix  or  vagina  through 
some  slight  abrasion  made  by  digital  examination.  It  is  believed, 
however,  that,  in  general,  the  placental  site  is  the  commonest  place 
for  septic  infection. 

Chemical  poisons  may  not  only  be  absorbed  from  the  products 
of  bacterial  growth  in  the  genital  canal,  but  may  be  formed  in 
the  body  itself.  Owing  to  the  rapid  absorption  accomj)anying  the 
involution  of  the  uterus,  associated  as  it  is  probably  with  a  process 
of  autolysis  of  the  muscle  fibres  due  to  the  action  of  intra-cellular 
ferments,  a  large  quantity  of  effete  material  is  poured  into  the 
blood,  to  be  disposed  of  by  the  excretory  organs.  This  must  be  the 
reason  why,  in  the  puerperal  state,  there  is  such  a  proneness  to  the 
outbreak  both  of  septicaemia  and  zymotic  diseases.     This  proneness 


Puerperal    Fevers.  999 

is  much  more  marked  at  the  full  term  of  pregnancy  than  in  the 
earlier  months,  the  uterus  then  having  attained  a  greater  size. 
Decomposition  of  retained  placenta  after  an  abortion,  though  it 
often  leads  to  febrile  disturbance  and  local  inflammation,  yet  is 
much  more  rarely  followed  by  fatal  septicaemia  than  the  same  con- 
dition after  full-term  delivery.  Excessive  muscular  exertion  and 
expenditure  of  nervous  energy  also  induces  a  peculiar  state  of  the 
blood  and  tissues,  more  prone  than  usual  to  decomposition,  as  has 
been  noticed  in  the  cases  of  hunted  animals  and  over-driven  cattle. 
It  is  probably  due  to  the  waste  products  formed.  This  cause  will 
operate  after  prolonged  or  difficult  labour. 

If  there  be  any  deficiency  in  the  excretory  organs,  effete  materials 
are  likely  to  accumulate  in  the  blood,  and  probably,  like  saprsemia 
caused  by  absorption,  predispose  to  septicaemia  by  diminishing  the 
vital  resistance  of  the  body.  Thus  it  has  been  observed  that  diseases 
and  functional  disturbances  of  the  kidneys  and  liver  predispose 
to  puerperal  septicaemia.  The  term  "  endogenetic  toxaemia  "  has 
been  applied  to  the  conditions  resulting  from  poison  generated 
within  the  body.  Some  transient  febrile  disturbances  may  be 
purely  of  this  nature,  as  when  pyrexia  results  from  a  toxin  absorbed 
from  the  intestines  in  consequence  of  constipation,  but  it  hardly 
exists  as  a  separate  variety  of  grave  puerperal  fever,  though  it  may 
be  one  of  the  predisposing  causes  of  septicaemia. 

Relation  of  Erysipelas  to  Paerperal  Fever. — It  was  held  at  one  time 
that  the  streptococcus  of  erysij^elas,  first  described  by  Fehleisen, 
was  a  specific  microbe  peculiar  to  that  disease.  Hence  it  was 
thought  that  the  origination  of  puerperal  septicaemia  by  contagion 
from  erysipelas  was  an  instance  of  a  zymotic  disease  being  con- 
verted into  septicemia.  Since,  however,  the  streptococcus  of 
erysipelas  cannot  be  distinguished  from  Streptococcus  pyogenes, 
either  microscopically  or  by  cultivation,  the  prevailing  opinion 
now  is  that  the  two  are  either  identical,  or  are  varieties  only,  of 
which  one  may  be  converted  into  the  other.  Thus  cutaneous 
erysipelas  difl'ers  from  septic  inflammations  only  in  the  fact  that 
the  microbe  is  limited  to  the  skin,  and  phlegmonous  erysipelas  is, 
in  all  cases,  a  septic  cellulitis.  Erysipelas  may  commence  at  a 
laceration  at  the  outlet  of  the  genital  canal  in  a  puerperal  woman, 
and  is  very  apt  to  be  followed  by  septic  inflammation  of  more 
internal  parts.  Thus  in  most  cases  there  are  symptoms  of  more 
or  less  inflammation  of  the  pelvic  organs  and  peritoneum,  namely, 
tenderness  of  the  uterus,  and  tenderness  and  distension  of  the 
abdomen.  The  disease  is  a  dangerous  one,  the  mortality  being 
similar  to  that  of  severe  puerperal  septicasmia. 


lOOO 


The  Practice  of   Midwifery. 


Fig.  485. — Death-rates  from  puerperal  fever  and  other  diseases  in  London, 
with  rain  at  Greenwich,  from  1881  to  1900.  KA.  Rainfall  at  Greenwich, 
inverted  curve.  P.F.  Puerperal  fever.  ER.  Erysipelas.  SEP.  Septicaemia 
and  pyaemia,  sc.  Scarlatina.  EH.  Rheumatic  fever.  Each  vertical 
division  corresponds  to  20  per  cent. 


There  is  considerable  evidence  to  show  that  the  contagion  of 
erysipelas  may  produce  in  the  puerperal  woman  not  only  erysipelas, 
but  ordinary  puerperal  septicaemia  without  any  erysipelatous  rash. 

Again,  when  the  mother  suffers  from  puerperal  fever  the  child  is 
sometimes  affected  by  erysipelas.      Dissection  wounds,  made  at  the 


Puerperal   Fevers.  looi 

necropsy  of  iDatients  who  died  from  puerperal  fever,  have  given  rise 
to  phlegmonous  erysipelas.  A  case  was  recorded  in  Italy,  in  which 
a  husband  had  intercourse  in  the  puerperal  period  with  his  wife, 
who  afterwards  died  from  puerperal  fever.  The  husband  had 
phlegmonous  erysipelas  of  the  penis,  which  spread  to  the  abdomen 
and  proved  fatal.  The  risk  of  infection  appears  to  be  greatest  from 
phlegmonous  erysipelas  in  which  suppuration  occurs,  and  there  is 
a  discharge  by  which  hands  or  clothes  may  be  contaminated. 
Several  cases  have  been  recorded  in  which  practitioners  while 
attending  to  wounds  of  this  nature  have  had  a  series  of  cases  of 
puerperal  fever  in  their  practice. 

Interesting  evidence  of  the  relation  of  puerperal  septicaemia  to 
erysipelas  and  other  diseases  is  obtained  from  diagrams,  represent- 
ing in  the  form  of  curves  the  percentage  above  or  below  the  mean 
of  deaths  from  various  diseases  in  successive  years.  The  diagram 
shown  in  Fig.  485  is  calculated  from  the  Eegistrar-General's 
statistics  for  the  period  1881 — 1900.^  It  will  be  noticed  that  the 
resemblance  of  the  curve  of  puerperal  fever  to  that  of  erysipelas  is 
exceedingly  close,  much  closer  than  to  that  of  septicaemia  and 
pyaemia  in  general.  The  year  1893,  in  which  the  most  marked 
maxima  of  both  diseases,  as  well  as  maxima  in  scarlatina  and 
rheumatic  fever,  occurred,  was  marked  by  prolonged  droughts  from 
March  to  June,  and  again  from  August  to  September.  The  periods 
of  greatest  mortality  occurred  from  two  to  three  weeks  after  the 
termination  of  each. 

Relation  of  Scarlatina  and  other  Zymotic  Diseases  to  Puerperal 
Fever. — Scarlatina  is  the  zymotic  disease  which  occurs  most  fre- 
quently in  the  puerperal  woman,  and  it  shows  in  her  certain 
peculiarities.  Pregnant  women  appear  to  have  a  special  immunity 
from,  and  puerperal  women  a  special  liability  to,  the  disease.  Thus 
Olshausen^  found  only  7  cases  recorded  of  scarlatina  during 
pregnancy,  as  compared  with  134  within  one  week  after  delivery. 
The  peculiarity  in  puerperal  women  is  that  the  sore  throat  is  almost 
always  slight,  but  yet  the  mortality  is,  or  used  to  be,  high,  compared 
with  the  usual  mortality  of  scarlatina,  and  used  to  correspond 
rather  to  that  of  severe  puerperal  fever.  In  134  cases  collected  by 
Olshausen,  it  was  48  per  cent. ;  in  34  cases  observed  at  the  Rotunda 
Hospital,  Dublin,  by  M'Clintock,^  it  was  29-7  per  cent. ;  in  25  cases 
observed  by  Halahan*  in  private  practice,  it  was  76  per  cent. ;    in 

1  For  further  details  on  this  subject  see  "  Collective  Investigation  Committee  Record, 
British  Medical  Association,"  Report  on  Puerperal  Pyrexia,  Galabin,  Vol.  11. 

2  "Puerperal  Scarlatina,"  Ojstet.  Journ.,  Vol.  IV. 
»  Dub.  Quart.  Journ.  Med.,  ISfU). 

4  Dub.  Quart.  Journ.  Med.,  1803. 


I002  The  Practice  of   Midwifery. 

13  cases  recorded  in  the  Collective  Investigation  Eecord,  it  was 
30*7  per  cent.  In  a  series  of  cases  in  Queen  Charlotte's  Lying-in 
Hospital,  observed  by  Brown, ^  the  complaint  was  quite  slight  in  all, 
and  there  was  no  death.  In  fatal  cases  of  puerperal  scarlatina 
some  of  the  symptoms  usual  in  puerperal  fever,  such  as  tenderness 
and  distension  of  abdomen,  and  scanty  or  offensive  lochia,  are  not 
uncommonly  present. 

More  recent  series  of  cases  in  lying-in  hospitals,  where  careful 
antisej)tic  precautions  were  taken,  have  been  recorded  by  BoxalP 
and  Meyer,^  of  Copenhagen.  There  was  no  mortality ;  no  puerperal 
fever  resulted,  and  the  average  of  pyrexia  in  other  puerperal 
cases  was  not  raised.  The  conclusion  suggested  is  that  the  chief 
danger  of  puerperal  scarlatina  is  that  it  predisposes  to  septicaemia 
as  a  complication.  It  may  be  hoped  that,  with  modern  perfection 
of  antisepsis,  the  dangerous  character  of  the  disease  may  be  much 
diminished.  Further  exjDerience,  however,  is  required  to  confirm 
this,  since  the  favourable  result  in  one  or  two  series  of  cases 
may  have  depended  upon  a  mild  type  of  the  disease. 

Modern  bacteriology  has  shown  that  in  scarlatina  there  is  often 
a  secondary  streptococcal  infection  in  local  lesions,  especially  in  a 
sloughy  throat.  The  most  probable  explanation  therefore  of  the 
occasional  connection  of  puerperal  fever  with  scarlatina  is  that  a 
streptococcal  infection  is  conveyed  from  the  scarlatinal  patient  to 
the  puerperal  woman. 

The  contagion  of  diphtheria  involves  a  risk  to  the  puerperal 
woman  similar  to  that  of  scarlatina.  For  streptococci  are 
generally  present  in  the  di})htheritic  membrane,  and  thus 
septicaemia  might  be  set  up.  Also  it  is  possible  for  true  diphtheria'* 
to  be  conveyed  to  a  wound  in  the  genital  canal.  Any  secondary 
lesions  due  to  streptococci  in  other  zymotic  diseases,  such  as 
enteric  fever,  may  also  set  up  puerperal  septicaemia.  Any  febrile 
disease  in  the  puerj)eral  woman  favours  the  occurrence  of  septi- 
caemia. Thus  even  the  slighter  zymotic  diseases  may  have  this 
effect,  either  through  the  pyrexia  simply,  or  through  some  other 
effect  upon  the  condition  of  the  blood.  The  pneumococcus  may 
cause  septic  inflammation  in  the  uterus  and  pelvis,  whether 
associated  or  not  with  pneumonia  in  the  lungs  (see  p.  994)  ;  but 
this  form  of  puerperal  septicaemia  is  a  very  rare  one. 

1  Brit.  Med.  Journ.,  Feb.  8,  1862. 

^  "Scarlatina  during  Pregnancy  and  the  Puerperal  State,"  by  Dr.  Boxall,  Trans. 
Obst.  Soc.  London,  1888,  Vol.  XXX.,  pp.  11  and  126. 

*  "  Ueber  Scharlach  bei  Wocherinnen,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1888,  14, 
p.  289. 

<•  Bumm,  Zeitsclir.  f.  Geb.  u.  Gyn.,  1895,  33,  p.  136. 


Puerperal   Fevers.  1003 

Effect  of  Difjicult  Labour. — If  tissues  are  severely  damaged,  as  by 
bruising  or  prolonged  pressure,  they  lose  more  or  less  their  faculty 
of  resisting  the  multiplication  of  organisms  within  them.  Hence 
after  difficult  instrumental  delivery,  or  too  prolonged  unassisted 
labour,  the  tissues  are  apt  to  be  infected  even  by  microbes  not 
previously  parasitic.  In  this  way  may  be  produced  either  sloughing 
of  the  tissues  with  decomposition  and  consequent  sapr^emia  or  even 
some  degree  of  septicaemia  from  anaerobic  saprophytes  (see  p.  997); 
or  septicaemia,  if  micrococci  gain  access,  even  though  not  derived 
from  any  virulent  source  of  contagion.  Thus  difficult  labour  may 
be  followed  by  peritonitis  similar  to  that  resulting  from  conveyed 
contagion.  The  proneness  to  the  reception  of  any  conveyed 
contagion  is  doubtless  also  increased  by  bruising  of  the  tissues. 

Decomposition  of  Retained  Placenta,  Clots,  or  Lochial  Discharge. — 
From  this  cause  sapraemia  is  generally  produced  in  the  first 
instance,  but  septicaemia  may  eventually  result,  the  decomposed 
organic  material  having  furnished  a  nidus  for  the  multiplication 
of  cocci  either  previously  present  in  the  vagina  or  vulva  or  intro- 
duced. The  true  nature  of  the  case  is  often  proved  by  rapid 
improvement  following  the  removal  of  expulsion  of  the  putrid 
material.  An  offensive  lochial  discharge  results  rather  from  the 
action  of  the  Bacillus  coli  or  other  saprophytes  than  from  the 
micrococci  of  suppuration.  In  the  most  virulent  forms  of 
septicaemia  there  may  be  no  offensive  smell. 

Cold,  Exposure,  or  Over-exertion. — In  a  certain  number  of  cases 
there  is  a  definite  history  of  the  commencement  of  pyrexia  imme- 
diately after  over-exertion,  exposure,  or  cold,  as,  for  instance, 
when  a  patient  gets  out  of  bed  within  a  few  days  after  delivery 
and  is  then  exposed  to  cold.  Probably  in  these  cases  there  is 
already  some  infection,  the  course  of  which  is  unfavourably 
influenced  by  the  exposure  or  exertion. 

Shock  or  Emotion. —It  is  well  known  that  the  efi"ect  of  mental 
excitement,  shock,  or  emotion  in  a  puerperal  woman  is  often  to 
cause  a  transient  elevation  of  temperature.  In  a  few  cases  a 
much  more  serious  effect  is  produced,  and  such  an  influence 
appears  to  be  the  starting-point  of  severe  and  even  fatal  septicaemia. 
I  have  known  a  case  in  which,  so  late  as  the  fourteenth  day,  a 
lady  was  greatly  agitated  by  one  of  her  children,  alone  in  the 
room  with  her,  being  nearly  choked  by  a  grape.  Pyrexia  com- 
menced from  that  time  and  ended  fatally.  It  is  probable  that  in 
these  cases,  as  in  those  originating  apparently  from  cold,  exposure, 
or  exertion,  there  is  some  latent  local  lesion,  which  is  unfavourably 
influenced  by  the  effect  of  the  emotion. 


1004  The  Practice  of   Midwifery. 

Contagion  from  Puerperal  Septicemia. — There  is  little  doubt  that 
the  most  dangerous  contagion  to  the  puerperal  woman  is  that 
derived  from  some  of  the  forms  of  puerperal  septicaemia  itself. 
This  is  most  strikingly  shown  by  the  series  of  cases  which  some- 
times occur  in  the  practice  of  the  accoucheur  or  midwife,  as  well  as 
by  the  experience  of  lying-in  hospitals.  Of  354  cases  reported  to 
the  Collective  Investigation  Committee  of  the  British  Medical 
Association,  24  were  placed  in  this  group.  These  show  the  same 
peculiarity  as  cases  ascribed  to  the  contagion  of  erysipelas,  namely 
a  mortality  much  above  the  average — 70'8  per  cent. — the  general 
mortality  being  47'4  per  cent.,  and  that  of  cases  ascribed  to  the 
contagion  of  erysipelas  70*6  per  cent. 

Other  Sources  of  Contagion. — Other  undoubted  sources  of  con- 
tagion are  post-mortem  poison  and  discharges  from  wounds, 
especially  if  associated  with  diffuse  cellulitis.  Gonorrlioea  should 
be  also  included,  as  the  gonococcus  is  allied  to  other  microbes 
of  supjmration  and  j^romotes  their  growth,  leading  to  a  mixed 
infection.  I  have  met  with  a  case  in  which  a  husband  admitted 
having  infected  his  wife  with  gonorrhoea  shortly  before  delivery. 
The  child's  eyes  were  destroyed  by  purulent  ophthalmia,  and  it 
died  of  jDyremia.  The  mother  suffered  from  puerperal  septicaemia, 
but  recovered.  In  general  it  appears  that,  as  in  the  non-puerperal 
state,  the  gonorrhceal  poison  tends  rather  to  cause  either  merely  a 
superficial  endometritis  or  limited  plastic  peritonitis  rather  than 
general  septicasmia.  Puerperal  sepsis  due  to  the  gonococcus  is 
generally  mild,  and  begins  at  a  late  stage,  about  a  week  after 
delivery.  Any  decomposing  matter  may  also  be  a  source  of 
danger.  In  the  case  of  post-mortem  poison,  it  aj)pears  that  a 
much  more  virulent  infection  is  derived,  within  a  short  time  after 
death,  from  cases  of  septicaemia,  or  any  diffuse  inflammation,  such 
as  peritonitis,  than  from  mere  products  of  decomposition.  But 
micrococci  which  have  been  acting  as  saprophytes  may  probably 
cause  puerperal  sepsis  in  some  conditions. 

Contagion  derived  from  any  source  of  suppuration  may  cause 
fatal  infection  to  the  puerperal  woman.  Thus  the  case  has  been 
recorded  in  America  of  a  medical  man  who  had  repeated  series  of 
cases  of  puerperal  septicaemia  in  his  practice,  notwithstanding 
disinfection  and  long  abstinence  from  practice  ;  and  this  has  been 
attributed  to  his  having  suffered  from  chronic  ozaena.  In  a  similar 
way  the  discharge  from  a  sinus  at  the  root  of  a  tooth,  or  the  sputa 
from  a  phthisical  lung,  may  be  a  source  of  danger. 

Insanitary  Conditions. — Insanitary  conditions  in  the  house, 
especially   defective   drains,   and   want   of   cleanliness,    are   often 


Puerperal   Fevers.  1005 

found  in  association  with  puerperal  fever.  Such  conditions  pro- 
bably act  merely  as  a  predisposing  cause,  by  impairing  the  patient's 
health,  or  possibly  some  poison  may  be  produced  which  is  the 
direct  agent  in  contngion.  In  general,  it  is  difficult  to  obtain 
positive  evidence  of  the  causation ;  but  sometimes  rapid  improve- 
ment follows  the  removal  of  the  patient  to  another  house,  or  the 
repair  of  the  defective  drain.  There  is  then  evidence  that  some 
continuous  poisonous  influence  was  being  exercised.  This,  how- 
ever, could  hardly  be  of  the  nature  of  septicEemia,  which  would 
not  be  likely  to  be  cured,  when  once  implanted,  by  removal  of 
the  original  cause.  Epidemics  of  puerperal  septicaemia  in  lying-in 
hospitals  have,  however,  been  attributed  to  defective  conditions 
of  their  drains,  or  to  collections  of  insanitary  refuse  in  their 
immediate  neighbourhood.  This  is  better  evidence  that  defective 
drains  may  originate  actual  septicaemia.  If  cocci  are  present  as 
saprophytes  in  decomposing  matter,  they  may  be  introduced  by 
sewer  gas;  and  then  may  be  disseminated  in  the  form  of  dust, 
and  reach  the  vulva  and  vagina  even  without  being  introduced  by 
hand  of  accoucheur  or  nurse.  Streptococci  have  actually  been 
detected  in  dust ;  and  the  occurrence  of  maxima  of  puerperal 
septicaemia  after  dry  seasons  is  evidence  in  favour  of  dust  playing 
some  part  in  its  dissemination.  At  any  rate,  it  is  certain  that 
streptococci  not  distinguishable  microscopically  from  the  pathogenic 
kind  do  occur  as  saprophytes. 

Contagious  Character  of  Different  Varieties. — Since  puerperal 
septicaemia  includes  many  varieties  of  disease,  it  may  be  expected 
that  the  contagious  character  would  vary  in  different  cases,  and  this 
expectation  is  confirmed  by  observation.  When  there  is  septic 
intoxication  or  sapraemia  only,  without  septic  infection,  there  can 
be  no  contagion.  In  localised  forms  of  inflammation,  such  as  the 
ordinary  pelvic  cellulitis,  although  micrococci  may  be  present,  there 
appears  to  be  practically  no  risk  of  contagion.  Much  has  yet  to  be 
learnt  about  the  circumstances  which  render  one  variety  more  con- 
tagious than  another.  But  two  facts  are  established :  (1)  that 
forms  of  puerperal  fever  themselves  derived  from  known  contagion 
are  most  likely  to  be  contagious ;  (2)  that  very  severe  and  fatal 
forms  are  more  likely  to  be  contagious  than  milder  forms.  Thus 
of  19  cases  reported  to  the  Collective  Investigation  Committee  of 
the  British  Medical  Association,  which  were  the  probable  source  of 
contagion  to  others,  all  but  one  were  fatal.  There  may  be 
contagion  not  only  to  other  puerperal  women,  but  to  the  infant  or 
attendants.     The  infant  may  die  from   pyciemia,  sometimes   from 


ioo6 


The  Practice  of   Midwifery. 


erysipelas.     Nurse  or  accoucheur  may  suffer  frora  sore  throat  or 
poisoned  hand. 

Pathological  Anatomy. — The  local  lesions  in  the  different 
forms  of  puerperal  fever  are  very  various,  and  de]3end  upon  the 
site  of  absorption,  and  the  mode  in  which  the  poison  spreads. 
Generally  there  are  inflammatory  changes  in  the  genital  canal  and 
its  neighbourhood,  and  these  may  extend  to  the  peritoneum  or 
cellular  tissue.     But  in  the  most  severe  forms  of  disease  the  poison. 


Fig.    486. — Uterus  showing  acute  sloughing  endometritis,   from  a  patient 
dying  of  puerperal  septicemia.     (Univ.  Coll.  Hosp.  Med.  School  Mus.) 


reaching  the  circulation  either  through  the  veins  or  lymphatics, 
may  set  up  so  intense  a  septicemia  that  death  results  with  little 
or  no  production  of  any  local  lesions.  The  local  changes  will 
be  described  according  to  the  tissues  in  which  they  are  found, 
commencing  with  those  most  directly  exposed  to  the  poison. 

Vaginitis  ;  Puerperal  Ulcers. — Wounds  of  the  vaginal  mucous 
membrane  may  acquire  an  unhealthy  appearance  and  suppurate 
instead  of  healing.  Frequently  the  surface  becomes  covered  with 
a  dirty-looking  greyish  deposit,  and  the  edges  and  surrounding 
tissue  become  oedematous.  Thus  are  constituted  the  so-called 
"  puerperal  ulcers."  They  are  most  frequently  situated  at  the  site 
of   a  perineal  laceration.     Sometimes  sloughing  of  the  damaged 


Puerperal  Fevers.  1007 

tissue  occurs,  esi^ecially  if  extensive  bruising  has  taken  place. 
Lacerations  of  the  cervix  may  be  converted  into  ulcers,  in  the  same 
way  as  those  of  the  vagina. 

Diphtheritic  Ulcers. — Sometimes  the  ulcers  become  covered  with 
a  diphtheritic  or  diphtheroid  deposit.  In  this  streptococci  are 
abundantly  present,  and  it  is  associated  with  a  deeper  destruction 
of  tissue  than  is  usual  in  the  ordinary  ulcers.  These  diphtheritic 
ulcers  are  rare  in  isolated  cases,  but  in  some  outbreaks  of  puerperal 
fever,  especially  in  lying-in  hospitals,  they  occur  in  almost  all  cases. 
They  do  not  appear  to  be  associated  with  the  ordinary  throat 
diphtheria,  nor  does  the  membrane  contain  the  bacillus  of  diph- 
theria. True  diphtheria  may,  however,  occasionally  affect  the 
genital  canal. ^  In  association  with  the  ulceration  of  lacerations, 
there  is  often  general  inflammation  of  the  whole  vaginal  mucous 
membrane,  which  becomes  congested  and  swollen. 

Endometritis,  Metritis. — Changes  in  the  uterus  are  the  most 
generally  present  of  all  local  lesions.  The  uterine  wall  is  always 
soft  and  oedematous,  the  involution  deficient.  The  condition  of  the 
endometrium  varies  according  to  the  microbes  present.  When  the 
active  agent  is  the  Bacillus  coli  or  other  saprophytes  the  surface  is 
rough  and  necrotic,  often  with  ragged  clehris  or  adherent  blood  clot 
attached.  In  the  most  virulent  form  of  streptococcic  infection  it 
may  be  smooth  and  without  necrosis.  There  is  always  a  layer  of 
infiltration  by  leucocytes  beneath  the  layer  of  necrotic  material 
lining  the  cavity  of  the  uterus,  bat  this  is  less  developed  in  pure 
streptococcic  infection  than  in  the  other  forms.  In  so-called  putrid 
endometritis  the  layer  of  leucocytic  infiltration  is  fairly  thick,  and 
while  saprophytes,  and  even  the  Staphylococcus  pyogenes  aureus, 
are  found  superficial  to  it,  beneath  it  the  tissue  may  present  almost 
a  normal  appearance.  In  cases  of  virulent  septic  endometritis  the 
layer  of  leucocytic  infiltration  is  poorly  developed,  and  streptococci 
are  often  found  not  only  in  this  layer,  but  infiltrating  the  tissues 
beneath  and  spreading  along  the  lymphatics. 

In  some  cases  there  is  nothing  beyond  oedema  of  the  muscular 
wall  of  the  uterus.  But  in  general  in  fatal  cases  the  tissue  is 
infiltrated  with  sero-purulent  fluid.  The  lymphatics  are  specially 
affected.  Sometimes  they  may  be  seen  under  the  peritoneal 
surface,  distended  with  pus,  more  especially  where  the  peritoneal 
covering  of  the  uterus  is  looser,  as  towards  the  sides,  near  the 
broad  ligaments.  Obvious  affection  of  the  veins  is  less  frequently 
seen,  l^ut  sometimes  the  thrombi  in  the   sinuses  become  broken 

1  Whitrid<<e  Williams,  Amer.  Journ.  Obslct.,  August,  1898;  Bumni,  Zeitschr.  f.  Geb  • 
u.  (iyn,,  ]8!ir,,  Bd.  :^3,  p.  136. 


ioo8 


The  Practice  of   Midwifery. 


down,  and  pus  is  found  in  the  veins.  Small  abscesses  in  the 
uterine  tissue  are  occasionally  formed.  Modern  bacteriological 
researches  show  that  many  of  the  slighter  and  more  transient 
forms  of  jDuerperal  pyrexia  are  really  a  streptococcic  endometritis, 
in  which  the  streptococci  are  isolated  from  the  deeper  tissues  by  a 
barrier  of  leucocytes,  and  no  general  sepsis  results. 

Pelvic  Cellulitis,  or  Parametritis ;  Lymphangitis. —  The  term 
"  parametritis  "  is  used  to  denote  inflammation  of  the  cellular 
tissue  near  the  uterus,  "  perimetritis  "  to  denote  inflammation  of 
the    peritoneum    covering    it   and    in   its   neighbourhood.       The 


Fig.  487. — Uterus  from  a  case  of  acute  septicasmia  following  criminal 
abortion,  ending  fatally  on  the  sixth  day.  There  is  a  tear  of  the  cervix 
at  the  internal  os,  which  in  the  recent  state  was  covered  by  a  diphtheritic 
membrane.  See  Fig.  490  for  the  temperature  chart.  (Univ.  Coll.  Hosp. 
Med.  School  Mus.) 

cellular  tissue  is  liable  to  become  inflamed  by  extension  of 
inflammation  from  the  uterus,  especially  at  the  sides  v/here  it 
joins  the  broad  ligaments.  Lacerations  of  the  cervix,  deep  enough 
to  reach  the  cellular  tissue,  are  specially  liable  to  be  a  starting- 
point.  This  is  proved  by  the  frequency  with  which  a  laceration  of 
the  cervix,  examined  long  after  the  delivery  which  originated  it,  is 
found  to  be  associated  with  a  band  of  cicatricial  tissue  in  the  broad 
ligament,  running  from  the  angle  of  the  laceration  toward  the 
pelvic  wall. 

The  bruising  of  the  tissue  in  prolonged  or  difficult  labour  may 
also  set  up  inflammation,  and  the  damaged  tissue  then  offers  less 
resistance  to  the  multiplication  of  organisms  within  it.     In  general 


Puerperal    Fevers.  1009 

the  cellulifcic  inflammation  is  unilateral,  or  more  marked  on  one 
side,  usually  on  the  left  side,  because  the  occi^Dut  is  commonly 
directed  that  way,  and  tears  the  cervix  more  deeply  on  that  side. 

In  the  more  severely  septic  forms  of  inflammation,  the  cellular 
tissue  is  infiltrated  with  turbid  semi-purulent  fluid,  containing 
micrococci.  The  lymphatics  are  specially  affected,  and  may  be 
filled  with  pus.  More  rarely  pus  is  seen  in  the  veins.  If  the 
inflammation  has  lasted  a  few  days,  small  collections  of  pus  in  the 
cellular  tissue  are  visible  to  the  eye. 

In  the  less  severe  form  of  inflammation,  which  constitutes  the 
ordinary  pelvic  cellulitis,  the  disease  is  limited,  and  does  not  lead 
to  general  septic  infection  throughout  the  body.  In  this  case,  the 
course  is  slower,  and  a  greater  amount  of  local  swelling  is  produced. 
The  swelling  is  due  to  the  effusion,  first  of  serum,  then  of  lymph. 
Suppuration  may  eventually  occur,  or  the  lymph  may  be  absorbed, 
leaving  generally  more  or  less  fibroid  induration.  No  positive 
line  of  distinction,  however,  can  be  drawn  between  the  ordinary 
pelvic  cellulitis  and  the  cellulitis  accompanying  the  more  virulent 
forms  of  puerperal  fever.  The  lymphatics  and  lymphatic  glands 
always  take  an  important  part  in  the  inflammation,  and  the  latter 
are  found  to  be  swollen.  In  the  milder  forms  of  disease,  the  glands 
appear  sometimes  to  interpose  a  barrier  to  the  further  spread  of 
inflammation. 

Parametritis  may  in  other  cases  arise,  generally  at  a  later  stage, 
secondary  to  salpingitis,  especially  when  this  goes  on  to  the 
formation  of  a  pyosalpinx.  In  such  cases  it  is  more  frequently 
bilateral. 

Site  of  the  Deposit  in  Pm'ametritis. — The  development  of  the  local 
inflammation  is  greatest  in  those  cases  which  do  not  proceed  to 
general  septic  infection,  and  which  run  a  prolonged  course.  The 
inflammation  generally  spreads  where  areolar  tissue  is  most 
abundant,  that  is,  between  the  folds  of  the  broad  ligament,  and 
thence  to  the  iliac  fossa.  From  thence  it  may  ascend  along  the 
sheath  of  the  psoas  and  iliacus  muscles,  or  along  the  ascending  or 
descending  colon,  according  to  the  side  affected,  to  the  region  of 
the  kidney  or  the  diaphragm.  It  may  also  come  forward  along 
the  muscular  sheath  to  Poupart's  ligament,  and  thence  ascend 
upwards,  between  the  peritoneum  and  the  abdominal  wall. 
Inflammation  may  also  extend  in  the  cellular  tissue  surrounding 
the  bladder,  or  in  that  between  the  pouch  of  Douglas  and  the 
vagina,  or  descend  upon  the  vaginal  walls.  These  courses,  how- 
ever, are  more  frequently  taken  by  cellulitis  of  non-puerperal  origin. 
When  suppuration  occurs,  the  abscess  most  frequently  opens  above 

M.  G4 


lOIO 


The  Practice  of   Midwifery. 


Poupart's  ligament.  Sometimes,  if  it  is  formed  within  the  sheath 
of  the  psoas  and  iliacus  muscles,  it  descends  near  the  femoral  vessels 
to  the  inside  of  the  thigh,  and  opens  below  Poupart's  ligament. 
At  other  times  it  opens  internally  into  the  vagina,  rectum,  colon, 
or  bladder.  Barely,  it  opens  beside  the  anus,  or  passes  through 
the  obturator  or  sciatic  foramen. 

Remote  Parametritis. — In  some  cases  inflammation  quickly  sub- 
sides in  the  neighbourhood  of  the  uterus,  but  proceeds  to  suppu- 
ration or  to  the  formation  of  considerable  deposit  at  some  distant 


Fig.  488. — Diagram  illustrating  spread  of  infection  (shaded  areas)  from  the 
cervical  canal  through  the  cervix  into  the  cellular  tissue  of  the  broad 
ligament,  and  through  the  uterine  wall  at  the  placental  site  to  the 
peritoneum. 

point  to  which  it  has  spread.  This  condition  has  been  called 
"  remote  parametritis."  In  such  cases,  an  abscess  or  cellulitic 
swelling  may  be  found  in  the  abdominal  wall,  near  the  kidney, 
near  the  sacro-iliac  joint,  or  elsewhere,  while  little  or  no  thickening 
can  be  detected  near  the  uterus. 

Peritonitis. — General  peritonitis  may  arise  through  extension  of 
septic  inflammation  to  the  peritoneum,  either  along  the  Fallopian 
tubes,  through  the  medium  of  the  lymphatics,  or  directly  by 
continuity  through  the  walls  of  uterus  or  the  broad  ligaments.  The 
peritoneal  cavity  is  then  found  to  contain  a  turbid,  foul-smelling 
fluid,    containing    micrococci,  and  more  or    less  pus.      There   is 


Puerperal  Fevers. 


lOI  I 


tympanitic  distension  of  the  intestines  from  an  early  stage,  and 
the  peritoneum  becomes  roughened,  as  well  as  injected  or  marked 
by  ecchymoses  in  the  situations  of  least  pressure.  It  is  only  in 
rapidly  fatal  forms  of  septicaemia,  and  in  those  in  which  infection 
takes  place  through  the  veins  rather  than  through  the  lymphatics, 
that  death  may  occur  without  the  development  of  any  sign  of 
peritonitis. 

Suppuration  of    the  tubes,  without  closure   of    the    ostium,    is 


^e  -t.v- 


FlG.  489. — Diagram  illustrating  the  spread  of  a  septic  thrombo  phlebitis 
from  the  placental  sinuses  into  the  ovarian  veins,  o.  v.,  and  from  a  lesion  in 
the  cervix  through  the  uterine  veins  into  the  internal  iliac  vein,  i.  i.  v. 

frequently  the  starting-point  of  general  peritonitis.  More  rarely 
a  pyosalpinx  of  old  standing  ruptures  during  or  after  delivery  and 
sets  up  peritonitis. 

In  milder  forms  of  inflammation,  the  exudation  is  less  purulent. 
More  lymph  is  produced,  and  adhesions  may  be  formed  between 
coils  of  intestine  or  other  organs.  In  spaces  limited  by  such 
adhesions,  collections  of  pus  may  be  formed,  and  thus  local 
abscesses  be  produced.  Inflammation  is  generally  most  marked 
in  the  pelvic  peritoneum. 

64—2 


IOI2  The  Practice  of   Midwifery. 

Pelvic  Peritonitis  or  Perimetritis. — When  the  septic  infection  does 
not  spread  to  the  j)eritoneum  generally,  the  pelvic  peritoneum  may 
become  inflamed  through  contiguity  to  inflamed  tissues  in  the 
jDelvis.  Thus,  in  cellulitis,  the  peritoneum  covering  the  broad 
ligaments  becomes  inflamed ;  and  inflammation  may  also  extend 
to  the  pelvic  peritoneum,  either  through  the  walls  of  the  uterus 
or  Fallopian  tubes,  or  reach  it  through  the  abdominal  extremity  of 
the  tubes.  In  the  limited  form  of  peritonitis,  the  inflammation  is 
generally  of  the  adhesive  kind,  but  localised  collections  of  serum 
or  pus  may  be  formed,  and  thus  is  constituted  an  encysted 
perimetritis. 

Ovaritis. — The  ovaries  are  often  especially  affected  in  connec- 
tion with  septic  forms  of  cellulitis  and  peritonitis.  The  ovary 
becomes  swollen,  the  stroma  infiltrated  with  turbid  serum,  and 
abscesses  may  be  formed  either  in  the  stroma  or  in  the  Graafian 
follicles. 

Salpingitis. — The  inflammation  may  siDread  along  the  Fallopian 
tubes,  so  that  these  become  filled  with  purulent  fluid.  One  of  the 
modes  in  which  peritonitis  may  arise  is  by  extension  of  this  inflam- 
mation along  the  tube  to  its  fimbriated  extremity,  or  through  the 
substance  of  the  tube-wall. 

Thrombosis  and  Pldehitis.  —  Thrombosis  in  the  veins  of  the 
placental  site  is  a  normal  condition  after  delivery.  Thrombosis 
in  uterine  or  pelvic  veins  is  also  not  uncommon,  apart  from  any 
septic  infection.  It  is  promoted  by  the  special  proneness  to  coagu- 
late which  exists  in  the  blood  of  puerperal  women,  and  by  the 
enfeeblement  of  the  circulation  during  rest  in  bed.  If  the 
thrombus  remains  healthy,  it  eventually  becomes  organised,  and 
the  vessel  is  partially  or  wholly  obliterated.  If,  however,  septic 
organisms  are  present,  the  thrombus  becomes  softened  and  breaks 
down,  fragments  of  it  are  carried  away  in  the  blood  stream,  and 
are  apt  to  form  emboli  in  the  lungs,  which  form  the  starting-points 
of  metastatic  abscesses.  Similar  abscesses  in  the  liver  or  kidneys 
may  originate  from  emboli  formed  by  clusters  of  micrococci,  which 
have  passed  through  the  pulmonary  circulation,  or  from  fragments 
detached  from  thrombi  formed  in  the  heart  or  pulmonary  veins,  or 
may  be  secondary  to  ulcerative  endocarditis. 

Septic  thrombi  may  be  formed  in  the  first  instance  in  several 
ways.  Organisms  may  reach  the  thrombi  of  the  placental  site 
from  decomposing  material  within  the  uterus.  Again,  the  presence 
of  septic  material  in  the  blood  may  give  rise  to  thrombosis  in 
various  parts.  Or  phlebitis  may  be  set  up  in  consequence  of  septic 
cellulitis  of  the  tissue  surrounding  the  vein.     Thrombosis  is  then 


Puerperal  Fevers.  1013 

the  consequence.  The  phlebitis  may  extend  from  the  point 
obstructed  by  the  thrombus,  and  the  vein  may  then  be  found  filled 
with  pus. 

Phlegmasia  Alba  Dolens. — This  may  arise  either  from  the  spread 
of  a  septic  cellulitis,  giving  rise  to  a  secondary  phlebitis,  or  from  the 
spread  of  a  septic  thrombosis  from  the  uterine  veins. 

Septicemia. — In  the  most  virulent  forms  of  septic  infection  of  the 
blood,  death  may  be  produced  almost  before  there  is  time  for  the 
development  of  local  lesions.  Even  peritonitis  may  in  these  cases 
be  sometimes  absent.  The  only  changes  then  found  at  an  autopsy 
are  an  altered  state  of  the  blood,  in  consequence  of  which  the 
lining  membrane  of  the  arteries  becomes  stained  with  blood  pigment 
shortly  after  death,  and  softening  and  swelling  of  glandular  organs 
such  as  the  spleen,  liver,  and  kidneys.  The  spleen  and  liver  are 
most  affected,  and  the  spleen  especially  may  be  almost  diffluent. 

Secondary  Affections  :  Pycemia. — If  the  disease  lasts  long  enough, 
secondary  affections  are  apt  to  be  developed,  but  the  more  virulently 
septic  forms  of  it  are  generally  so  rapidly  fatal  that  it  is  only  in  a 
small  proportion  of  cases  that  the  type  of  pyaemia  is  assumed. 
Pya^mic  deposits  in  the  viscera,  and  pysemic  inflammation  of  more 
external  parts,  such  as  the  joints,  are  not  often  found  associated 
together.  The  former  belong  to  those  cases  in  which  the  spread  of 
the  poison  takes  place  chiefly  through  the  vessels,  producing 
emboli,  the  latter  to  those  in  which  it  spreads  through  the 
lymphatics.  As  might  be  exj)ected,  pytemic  deposits  are  commonest 
in  the  lungs,  since  emboli  originating  from  thrombi  in  the  veins 
are  likely  to  be  arrested  there.  Next  to  the  lungs  the  organs  most 
often  affected  are  the  kidneys.  General  septic  nephritis  may  also 
occur. 

Ulcerative  Endocarditis  is  occasionally  found,  but  is  compara- 
tively rare.  Micrococci  are  found  in  the  ulcerated  tissue  of  the 
cardiac  valves,  and  secondary  embolic  foci  of  inflammation  are  apt 
to  result  in  various  parts. 

Septic  Panophthalmitis  is  the  result  of  embolism  of  the  ophthalmic 
artery.  It  leads  to  suppuration  and  destruction  of  the  eye,  and  is 
generally  followed  by  death. 

Pleurisy  and  Pericarditis  may  result  from  extension  of  inflamma- 
tion through  the  diaphragm  from  the  peritoneum,  or  may  be 
secondary  to  pneumonia,  generally  of  pyaemic  origin. 

Pneumonia  may  arise  from  metastatic  pyaemic  deposit.  Broncho- 
pneumonia and  lobular  pneumonia,  apart  from  pyaemia,  are  also 
liable  to  occur  in  connection  with  septic  disturbances  after  delivery, 
and  are  probably,  in  most  cases,  streptococcic  in  origin. 


IOI4 


The  Practice  of   Midwifery. 


Joints  are  not  uncommonly  affected  by  swelling  and  inflammation 
which  may  go  on  to  suppuration,  as  in  the  case  of  surgical  pyaemia. 
In  other  cases  the  pain  and  swelling  are  only  temporary.  The 
joints  of  the  upper  extremity,  shoulders  and  elbows,  are  most 
frequently  affected,  next  to  them  the  knees. 

Local  Inflammation  of  Cellular  Tissue,  especially  in  the  limbs, 
also    occur   often  accompanied  by  redness   of   the  skin  over  the 


DAYorDIS. 

1 

2 

3 

4 

5 

6 

0 

F 
106° 
105° 
104° 
103° 
1  0  2° 
101  ° 
100° 
99° 
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Fig-.  490. — Temperature  chart  of  a  case  of  acute  septicfemia  following  criminal 
abortion,  terminating  fatally  on  the  sixth  day.     (See  Fig.  487). 


swelling.  The  swellings  may  subside,  or  go  on  to  the  formation 
of  abscesses.  In  some  cases  the  inflammation  is  obviously  due 
to  embolism,  and  may  then  lead  to  vesication  and  even  superficial 
sloughing. 

Among  the  secondary  affections  sometimes  observed  are  inflam- 
mation and  suppuration  of  parotid  or  thyroid,  suppuration  of  ears, 
and  meningitis. 

Of  the  354  cases  reported  to  the  Collective  Investigation  Com- 
mittee, there  were  15  in  which  pysemic  abscesses  in  the  joints  or 


Puerperal   Fevers.  1015 

other  external  parts   occurred,  20   in  which    there  were  signs  of 
secondary  pneumonia. 

In  the  Nomenclature  of  the  Eoyal  College  of  Physicians,  the 
term  "  puerperal  fever  "  is  discarded  for  the  purpose  of  death  certifi- 
cates; and  the  return  is  to  be  made  as  septicaemia,  pyaemia,  or 
according  to  the  local  affection  present.  Puerperal  fever  has, 
however,  since  been  made  by  Parliament  a  notifiable  disease. 
For  the  purpose  of  notification,  puerperal  fever  should  be  regarded 
as  including  the  contagious  forms,  septicaemia  and  pyaemia,  but  not 
sapraemia. 

Symptoms  and  Course. — In  the  great  majority  of  cases,  the 
disease  commences  within  the  first  five  days  after  delivery.  The 
third  day  is  the  commonest  day  of  onset,  especially  in  cases  arising 
from  infection  conveyed  from  some  virulent  source,  such  as 
puerperal  fever  or  erysipelas.  Puerperal  scarlatina  and  erysipelas 
also  appear  most  frequently  on  the  third  day.  In  the  cases  of 
puerperal  pyrexia  reported  to  the  Collective  Investigation  Com- 
mittee the  days  of  onset  stand  in  the  following  order  of  frequency  : — 
third,  second,  fourth,  first,  fifth.  In  some  cases  the  pyrexia 
commences  before  delivery.  In  these  it  must  be  presumed  that 
the  infection  is  received  at  an  early  stage  of  labour,  or  previous  to 
labour.  Cases  are  comparatively  rare  in  which  the  first  outbreak 
is  noticed  after  the  end  of  a  week.  It  is  probable  that,  in  most  of 
these,  there  has  been,  at  an  earlier  period,  some  local  morbid  action 
and  some  febrile  disturbance  which  has  escaped  notice.  The 
majority  of  them  are  either  instances  in  which  the  outbreak  of  the 
fever  is  attributed  to  some  exposure,  premature  exertion,  or  nervous 
shock  occurring  at  a  rather  late  period  after  delivery ;  or  they  are 
cases  in  which  there  is  a  late  manifestation  of  a  localised  pelvic 
cellulitis,  the  early  symptoms  of  which  may  have  been  slight  in 
degree,  and  may  easily  have  passed  unobserved.  The  thrombotic 
form  of  septicaemia  also  begins  to  cause  symptoms  rather  late, 
sometimes  as  much  as  a  week  after  delivery. 

The  symptoms  vary  greatly  according  to  the  forms  which  the  local 
manifestations  of  the  disease  assume.  The  most  general  symptom 
is  the  pyrexia  itself.  In  the  milder  forms  of  disease,  limited  to 
a  septic  endometritis,  the  elevation  may  not  rise  above  101°  or 
102°  F.,  and  may  be  of  short  duration.  In  the  more  virulent  forms 
of  infection  the  initial  rise  is  often  rather  sudden,  to  a  height  such 
as  105  F.,  or  more  (Fig.  490).  In  this  case  rigors  accompany  the 
rise,  and  often  form  the  first  serious  symptom  which  attracts  notice. 
When  the  rise  of  temperature  is  gradual,  as  from  septic  intoxication 


ioi6  The  Practice  of   Midwifery. 

due  to  the  slow  decomposition  of  something  retained  within  the 
uterus,  rigors  may  be  absent.  In  severe  or  fatal  cases  the 
temperature  quickly  reaches  a  considerable  elevation,  such  as 
103°  or  104°  F.  The  pulse  rises  with  the  temperature.  In  mode- 
rately severe  cases  the  rate  may  be  as  much  as  120;  in  the  graver 
forms  of  the  disease  it  may  reach  140,  and  before  a  fatal  issue 
may  be  as  high  as  160  or  170.  As  a  rule  the  temperature  tends  to 
rise  ^progressively  towards  a  fatal  issue.  But  in  some  of  the  most 
virulently  septic  forms  of  disease,  especially  when  purulent 
peritonitis  exists,  the  temperature  falls  again,  after  an  initial 
rise,  while  the  pulse  continues  to  rise,  and  the  general  conditions 
become  aggravated.  The  pulse  is,  therefore,  frequently  a  more 
reliable  sign  of  danger  than  the  temperature.  As  the  moribund 
condition  is  approaching,  the  temperature  may  become  subnormal. 
In  the  more  protracted  forms  of  disease,  which  take  the  form  of 
phlebitic  septicaemia  or  pyeemia,  there  are  usually  great  oscillations 
of  temperature  ;  and  the  successive  elevations  are  often  accom- 
panied by  repeated  rigors,  perhaps  at  intervals  of  several  days. 
When  the  fever  is  continuous,  the  initial  rigors  are  generally 
not  repeated. 

Next  to  the  pyrexia,  the  most  general  symptom  is  tenderness  of 
the  uterus,  accompanied  by  a  deficiency  of  contraction  and 
involution.  Usually  there  is,  in  addition,  pain  referred  to  the 
uterine  region,  and  indicating  endometritis  or  metritis.  Another 
symptom  common  to  most  of  the  graver  forms  of  the  disease  is 
enlargement  and  tenderness  of  the  spleen. 

The  tendency  to  delirium  is  slight  in  proportion  to  the  degree  of 
pyrexia,  compared  with  that  which  occurs  in  many  other  forms  of 
fever.  When  fever  is  high  there  is  generally  more  or  less 
wandering  at  night,  but  the  patient  can  usually  be  roused  to 
understand  and  answer.  In  grave  septicaemia,  the  face  is  anxious 
in  expression,  but  the  mind  is  often  quite  clear,  and  the  patient 
may  be  quite  unaware  of  her  grave  condition.  Severe  headache  is 
common.  The  tongue  may  remain  moist  and  clean  in  slight 
attacks,  but  is  generally  coated,  and  eventually  may  become  dry 
and  glazy  or  brown.  Sweating  is  frequent,  especially  when 
oscillations  of  temperature  occur. 

Among  the  most  prominent  of  the  graver  symptoms  are  diminu- 
tion or  suppression  of  the  lochia  and  of  the  milk. 

In  cases  of  acute  sloughing  or  putrid  endometritis  the  lochia  are 
often  abundant,  at  any  rate  at  first,  and  very  offensive.  Such  an 
offensive  character  in  the  discharge  may  either  precede  or  follow 
the   onset   of   the   pyrexia.      In  rare   cases,  in  which   the   fever 


Puerperal   Fevers.  1017 

commences  before,  or  immediately  from  the  time  of  delivery,  there 
is  an  almost  complete  suppression  of  lochial  discharge  from  the 
outset. 

In  some  cases,  more  especially  when  the  condition  is  one  of 
acute  septicaemia,  due  to  a  streptococcic  infection,  the  lochia  are  but 
little  altered  except  in  quantity,  and  there  may  be  no  odour. 
Interference  with  lactation  is  not  so  general  a  symptom  as  some 
alteration  of  the  lochial  discharge,  but  there  is  diminution  or 
suppression  of  milk  in  the  graver  cases  of  fever,  if  at  all  prolonged. 
If  the  onset  of  fever  is  early,  on  the  first,  second,  or  third  day,  the 
secretion  of  milk  may  be  entirely  prevented.  In  other  cases,  it 
diminishes  and  ceases  as  the  constitutional  state  becomes  grave. 

Vomiting  and  diarrhoea,  but  especially  the  latter,  are  symptoms 
which  generally  indicate  a  severely  septic  form  of  fever.  Vomiting 
is  especially  associated  with  general  peritonitis,  but  may  occur 
without  evidence  of  peritonitis,,  as  a  symptom  of  the  pyrexia, 
especially  when  the  temperature  rises  to  a  high  level.  When 
diarrhoea  occurs,  the  motions  are  often  very  offensive,  as  if  some 
septic  material  were  evacuated  through  the  intestines.  The 
diarrhoea  does  not  generally  commence  quite  at  the  outset,  but  after 
the  disease  has  been  established  for  a  day  or  two. 

Bashes. — A  miliary  eruption  frequently  results  from  the  sweating 
which  is  usual  in  any  form  of  puerperal  pyrexia,  even  that  of  a 
slight  and  evanescent  kind.  There  may  be  an  evanescent  general 
scarlet  rash,  suggestive  of  the  rash  of  scarlatina,  but  not  always 
followed  by  desquamation.  Again,  there  may  be  limited  erythematous 
blotches  resembling,  and  probably  identical  with,  erysipelas.  In 
other  cases  a  roseolous,  papular,  or  petechial  rash  is  observed.  The 
latter  forms  of  rash,  at  any  rate,  are  to  be  regarded  as  merely 
symptoms  of  septicaemia,  and  generally  indicate  a  grave  and 
dangerous  form  of  the  disease. 

The  remaining  symptoms  must  be  described  under  the  headings 
of  the  special  varieties  of  fever. 

SejJticcsmic  Endometritis. — There  is  pyrexia,  which  may  be  only 
moderate  in  degree  ;  rigors  may  or  may  not  occur.  The  uterus  is 
tender,  often  painful,  and  its  normal  involution  is  retarded.  Milk 
is  usually  diminished  or  suppressed,  if  pyrexia  is  considerable. 
The  lochial  discharge  is  diminished  or  suppressed  in  severe  cases, 
but  may  continue  of  normal  amount  in  mild  ones.  Its  continuance 
is  a  favourable  sign.  The  discharge  may  be  offensive.  According 
to  modern  bacteriological  researches,  this  variety  includes  by  far 
the  largest  proportion  of  all  cases  of  puerperal  sepsis. 

General  Peritonitis. — General   peritonitis   is   by   far    the    most 


ioi8  The  Practice  of   Midwifery. 

frequent  variety  of  the  severe  and  fatal  forms  of  sepsis.  In  this 
form,  the  rigor  and  rise  of  temperature  are  generally  accompanied 
or  quickly  followed  by  acute  abdominal  pain  and  tenderness,  com- 
mencing near  the  uterus  and  extending  over  the  whole  abdomen. 
The  patient  hes  on  her  back  with  the  knees  drawn  up,  as  in  ordinary 
IDeritonitis.  The  abdomen  becomes  distended  and  tympanitic 
from  paralysis  of  the  sympathetic  nerves.  Sometimes  individual 
coils  of  intestine  may  be  seen  standing  out,  and,  before  death,  the 
distension  often  becomes  enormous.  Vomiting  is  frequent,  and 
the  contents  of  the  upper  part  of  the  intestine  are  often  ejected, 
as  well  as  those  of  the  stomach.  Vomiting  of  coffee-ground  fluid 
is  a  very  unfavourable  sign.  The  pulse  is  small  and  rapid,  but 
soon  becomes  feeble  rather  than  resistant.  It  is  usually  a  more 
important  indicator  of  danger  than  the  temperature.  At  the  early 
stage,  and,  in  the  less  virulent  forms  of  disease,  throughout  the 
whole  course,  the  bowels  are  confined,  as  in  ordinary  peritonitis. 
But  in  the  more  virulent  septicaemia,  diarrhoea  soon  comes  on, 
and  the  motions  are  frequent,  liquid,  and  offensive.  The  skin 
becomes  sallow,  or  has  a  yellowish  tint,  and  there  is  a  peculiar 
disagreeable  smell  about  the  breath.  Pain  and  tenderness  are 
symptoms  not  invariably  present.  In  some  of  the  gravest  forms 
of  septicemic  peritonitis,  especially  when  the  inflammation  is  of 
the  suppurative  kind,  they  are  absent.  The  peritonitis  then  only 
reveals  itself  by  the  abdominal  distension,  associated  with  the  rapid, 
feeble  pulse,  and  frequently  with  vomiting  and  diarrhoea.  Enough 
fluid  may  be  present  to  give  a  manifest  fluid  thrill,  and  dulness 
in  the  dependent  parts  of  the  peritoneal  cavity.  In  milder  forms 
of  fever,  on  the  other  hand,  the  pain  and  tenderness  may  not 
extend  far  beyond  the  neighbourhood  of  the  uterus,  or  the  general 
tenderness  may  be  evanescent.  Abdominal  distension  does  not 
then  proceed  beyond  a  moderate  degree.  If  a  fatal  termination 
is  approaching,  the  extremities  become  cold,  the  hands  pick  at 
the  bed-clothes,  the  pulse  cannot  be  felt  at  the  wrist,  and  the 
patient  often  becomes  comatose.  When  the  disease  proves  fatal, 
death  usually  occurs  within  a  week,  not  uncommonly  in  four  or 
five  days. 

If  the  course  of  the  disease  is  protracted,  and  the  peritonitis  is 
of  the  adhesive  form,  tangible  masses  may  after  a  while  be  formed 
in  the  abdomen  through  the  matting  together  of  coils  of  intestine. 
Sometimes  suppuration  takes  place  within  a  space  limited  by 
adhesion.  An  abscess  is  then  formed  which  may  point  on  the 
surface  of  the  abdomen,  or,  less  frequently,  open  into  the  intestine, 
vagina,  or  bladder.     Such  an  abscess  may  leave  a  sinus  which  long 


Puerperal   Fevers. 


1019 


continues  to  discharge.     In  some  cases,  apart  from  general  pyaemia, 
a  secondary  abscess  of  the  liver  has  been  formed. 

Pure  Seyticamia. — In  some  cases  the  disease  kills  apparently  by 
the  intensity  of  the  poison  without  the  production  even  of  perito- 
nitis, and  before  there  is  time  for  any  metastatic  inflammations  to 
arise.  There  is,  however,  almost  invariably  tenderness  of  the 
uterus,  as  evidence  of  some  local  inflammation  of  that  organ,  and 
there  may  be  "  puerperal  ulcers  "  in  the  vagina.  The  abdomen 
may  become  distended  to  some  extent  from  the  impression  pro- 
duced by  the  poison  upon  the  sympathetic  nerves,  even  though  no 


DAYofDIS. 

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2 

3 

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Fig.  491. — Temperature  chart  of  a  case  of  saprfemia  clue  to  retained 
membranes.  Evacuation  and  washing  out  of  uterus  on  eighth  day, 
followed  by  immediate  fall  of  temperature. 

evidence  of  peritonitis  is  found  post  mortem.  There  are  rigors  at 
the  commencement,  and  the  pulse  and  temperature  rise  rapidly  to 
a  high  level.  Diarrhoea  is  common.  There  is  an  absence  of  pain, 
but  a  good  deal  of  wandering  of  mind.  Tenderness  and  enlarge- 
ment of  the  spleen  may  be  made  out.  Death  generally  occurs  in 
three  or  four  days. 

Sap'iemia,  or  Septic  77ifo.xicaiio?i.— Saprsemia  produced  merely  by 
the  absorption  of  chemical  products  of  decomposition,  without  the 
multiplication  of  organisms  in  the  blood  or  tissues,  is  probably 
rarely  seen  in  its  pure  form  in  the  puerperal  woman.  The  chief 
examples  of  it  are  to  be  found  in  cases  of  decomposition  of  retained 
placenta  after  premature  labour  or  abortion,  when  the  symptoms 


I020  The  Practice  of   Midwifery. 

subside  rapidly,  sometimes  within  a  few  hours,  after  the  removal 
of  the  source  of  mischief.  I  have,  however,  met  with  the  case  of  a 
primipara  who  had  severe  rigors  little  more  than  twelve  hours 
after  delivery.  Twenty-four  hours  after  delivery,  the  lochia  were 
suppressed,  the  pulse  was  160,  temperature  102°  F.,  and  the  patient 
delirious.  The  case  had  all  the  aspect  of  the  most  virulent  form 
of  puerperal  septicaemia  derived  from  contagion.  Since,  however, 
careful  inquiry  failed  to  indicate  any  possible  source  of  contagion, 
it  was  decided  to  wash  out  the  uterus,  although  there  was  no  evidence 
of  decomposition.  After  twelve  hours,  the  temperature  had  become 
normal,  the  pulse  had  fallen  to  90,  and  the  lochia  had  returned. 
The  patient  recovered  without  further  disturbance  (see  Fig.  491). 

The  symptoms  of  sapraemia  consist  of  the  fever  itself,  frequently 
with  the  addition  of  effects  commonly  produced  by  pyrexia,  such  as 
vomiting,  headache,  pains  in  the  back  and  limbs,  sometimes  delirium. 
Eapid  recovery  after  the  removal  of  some  decomposing  material  can 
alone  prove  that  the  disease  was  solely  or  mainly  sapraemia.  But 
it  may  always  be  hoped  that  such  is  the  case,  when  the  lochial 
discharge  is  offensive,  especially  if  it  is  found  to  contain  saprophytes 
and  not  streptococci,  when  the  pyrexia  has  been  only  recently 
developed,  and  when  there  is  no  evidence  of  local  inflammation, 
such  as  metritis,  peritonitis,  or  cellulitis. 

Vascular  or  Phlebitic  Septiccsmia. — Distribution  of  poisonous 
material  into  the  blood  from  septic  thrombi  may  commence  within 
two  or  three  days  after  delivery,  but  frequently  occurs  only  at  a 
later  period.  Symptoms  of  a  slight  pelvic  cellulitis  may  have 
preceded,  or  nothing  abnormal  may  have  been  noticed.  At  the 
commencement  there  is  usually  a  marked  rigor,  and  sudden  rise 
of  pulse  and  temperature.  The  fever  is  not,  however,  continuous, 
but  interru23ted  by  remissions  or  complete  intermissions.  Profuse 
jDerspiration  generally  accompanies  the  fall  of  temperature,  and 
thus  the  disease  may  resemble  malarial  fever.  In  the  majority  of 
cases  there  is  no  iDeritonitis,  and  the  abdomen  is  then  usually  free 
from  any  general  tenderness  or  distension.  If  a  vaginal  examina- 
tion is  made,  a  slight  cellulitic  thickening  may  often  be  felt  near 
the  uterus,  but  not  sufficient  to  account  for  the  degree  of  fever. 
Kigors  are  apt  to  be  repeated  with  the  successive  rises  of  tempe- 
rature. Eecovery  may  take  place  without  the  j)roduction  of  any 
metastatic  inflammation,  or  the  disease  maybe  merged  into  pyemia. 
It  is  in  this  form  of  disease  especially  that  pyaemic  abscesses  in  the 
lungs  and  other  viscera  are  apt  to  be  formed  by  septic  emboli. 
The  course  of  the  disease  is  apt  to  be  more  protracted  than 
other  forms  of  puerperal  fever.     If   it  is  converted  into  pyaemia. 


Puerperal   Fevers.  1021 

the  fever  becomes  continuous,  and  the  general  condition  more 
grave. 

Pycsmia. — In  all  cases  the  course  of  which  is  protracted,  metastatic 
inflammation  is  apt  to  arise.  Such  inflammation  chiefly  occurs  in 
the  cellular  tissue,  especially  of  the  limbs,  in  the  joints,  and  in  the 
lungs  and  other  viscera.  Both  inflammation  of  the  cellular  tissue 
and  that  of  the  joints  may  subside  without  going  on  to  the  forma- 
tion of  abscess.  Out  of  354  cases  of  puerperal  pyrexia  reported  to 
the  Collective  Investigation  Committee,  there  were  14  in  which 
external  pyemic  abscesses  were  formed.  The  mortality  in  these  was 
28"5  per  cent.,  the  average  mortality  of  the  whole  number  being 
47'4  per  cent.  It  therefore  appears  that  although  a  patient  may 
sink  from  exhaustion  from  the  suppuration  of  external  abscesses,  yet 
the  cases  in  which  these  occur,  being  comparatively  protracted,  are 
not  the  most  dangerous.  The  occurrence  of  pneumonia  or  pleurisy 
in  the  course  of  puerperal  septicaemia  does  not  necessarily  imply  the 
formation  of  pyemic  deposits  in  the  lung,  but  it  frequently  does  so, 
and  is  always  of  serious  import.  Out  of  the  same  354  cases, 
secondary  pneumonia  or  pleurisy  was  noted  in  20  cases,  the  mortality 
of  which  was  70  per  cent.  Pericarditis  is  less  frequently  observed. 
It  is  also  of  serious  import.  Occasionally,  both  external  and  visceral 
pyaemia  are  combined  in  the  same  person. 

Pelvic  Cellulitis  (Parametritis)  and  Pelvic  Peritonitis  {Perimetritis). 
— Pelvic  cellulitis  and  pelvic  peritonitis  are  diseases  which  occur 
independently  of  pregnancy  as  well  as  in  the  puerperal  state.  By 
many  authors  the  description  of  them  is  separated  altogether  from 
that  of  puerperal  fever,  on  the  ground  that  they  do  not  necessarily 
arise  from  any  septic  origin.  This  is  so  far  true  that  they  may  be 
due  to  a  traumatic  cause,  such  as  the  effects  of  difficult  instrumental 
delivery.  Even  in  this  case,  however,  though  there  may  be  no 
virulent  infection  conveyed  from  without,  yet  the  spreading 
cellulitic  inflammation  is  probably  associated  with  the  presence  of 
micrococci,  especially  in  those  cases  which  end  in  suppuration.  The 
explanation  may  be  that,  when  the  vitality  of  the  tissues  is  lowered 
by  mechanical  injury,  organisms  which  are  commonly  present 
are  able  to  multiply  in  them.  It  is  probable,  therefore,  that, 
in  the  puerperal  woman,  parametritis  and  perimetritis  never 
occur  altogether  apart  from  some  septic  element,  although  there 
may  have  been  neither  any  conveyance  of  special  poison,  nor 
manifest  decomposition  in  the  genital  passages.  Some  degree  of 
parametritis  is  often  associated  with  grave  forms  of  septicaemia. 
But,  if  the  parametritis  is  extensive,  and  forms  the  main  feature 
in  the  case,  it  is  usually  implied  that  there  is  no  general  septic 


I022  The  Practice  of   Midwifery. 

infection ;  and  that,  if  any  special  infection  has  been  received,  its 
effects  are  limited  to  the  local  inflammation.  Parametritis  is  thus 
an  example  of  a  condition  which  cannot  be  excluded  from  the  group 
of  septic  diseases,  but  yet  the  prognosis  of  which  is  generally 
favourable. 

Apart  from  pregnancy,  primary  parametritis  hardly  occurs, 
unless  as  the  result  of  septic  absorption  from  some  wound  or 
operation  on  the  uterus.  Some  parametritis,  however,  is  often 
associated  with  perimetritis,  and  arises  by  extension  of  inflam- 
mation from  the  salpingitis  which  was  an  antecedent  to  the 
perimetritis. 

In  the  puerperal  woman  either  parametritis  or  perimetritis  may 
be  primary,  and  the  former  is  generally  associated  with  some  peri- 
metritis, from  extension  of  the  inflammation  from  the  cellular 
tissue  to  the  peritoneum  covering  it. 

The  symptoms  of  primary  puerperal  perimetritis  resemble  those 
of  general  peritonitis,  except  that  they  are  less  severe,  and  pain  and 
tenderness  are  limited  to  the  neighbourhood  of  the  pelvis. 

In  parametritis,  as  in  other  forms  of  puerperal  pyrexia,  the 
onset  is  generally  within  the  first  five  days.  It  is  not,  indeed, 
uncommon  to  meet  with  cases  in  which  the  onset  is  insidious,  and 
which  only  attract  attention  at  a  much  later  period,  sometimes 
several  weeks  after  delivery,  when  the  woman  has  begun  to  get 
about.  But,  in  most  such  cases,  there  has  been,  shortly  after 
delivery,  pyrexia  with  slight  pain,  the  cause  of  which  has  been 
overlooked. 

The  attack  generally  commences  with  a  rigor  and  sudden  rise  of 
temperature.  The  temperature  commonly  reaches  102°  F.  and  may 
rise  to  103°  or  101°  F.  The  pulse  is  not  so  frequent  in  proportion  as 
in  general  septicaemia,  and  rarely  exceeds  120.  With  the  pyrexia 
commence  pain  and  tenderness  in  the  lower  part  of  the  abdomen, 
generally  on  one  side.  The  degree  of  pain  and  tenderness  depends 
much  upon  the  extent  to  which  the  peritoneum  is  involved  in  the 
inflammation;  and  in  some  cases  they  are  slight.  The  pain  fre- 
quently subsides  in  a  few  days,  while  the  tenderness  remains. 
When  the  peritoneal  affection  is  prominent,  there  may  be  also 
nausea  and  vomiting,  an  anxious  expression  of  countenance,  and 
some  distension  of  the  lower  abdomen.  If  the  exudation  surrounds 
the  bladder  and  rectum,  pain  on  defecation  and  micturition  comes 
on  at  a  later  stage,  and  there  is  also  vesical  tenesmus.  The  bowels 
are  generally  constipated.  If  a  mass  is  formed  in  the  broad  liga- 
ment, the  patient  lies  with  the  thigh  on  the  affected  side  drawn  up, 
and  cannot  extend  it  without  pain.     There  is  also  pain  down  the 


Puerperal   Fevers.  1023 

thigh,  and  in  the  lumbar  region,  from  pressure  on  the  nerves.  The 
temperature  generally  reaches  its  height  in  two  or  three  days.  Its 
course  afterwards  is  irregular,  and  there  are  usually  morning  remis- 
sions or  intermissions,  especially  as  the  disease  is  subsiding.  Pro- 
fuse sweating  often  accompanies  the  remissions.  While  the  pyrexia 
is  considerable,  there  is  usually  headache  and  sleeplessness,  and  the 
tongue  is  coated.  The  fever  may  subside  within  a  week,  or  may  be 
prolonged  with  an  irregular  course  for  several  weeks.  Repeated 
rigors,  with  successive  elevations  of  temperature  to  a  high  point, 
generally  indicate  suppuration. 

Inflammatory  thickening  near  the  uterus  may  be  formed  within 
a  few  days,  but  it  is  generally  not  till  after  a  week  that  any  con- 
siderable mass  of  exudation  is  formed.  On  vaginal  examination  a 
swelling  is  then  felt,  usually  on  one  side  of  the  uterus.  It  may  be 
rounded  or  may  be  somewhat  wedge-shaped,  occupying  the  position 
of  the  broad  ligament,  the  broad  end  of  the  wedge  spreading  out 
toward  the  pelvic  wall,  to  which  it  is  attached  (see  Fig.  492, 
p.  1024).  Generally  a  laceration  of  the  cervix  may  be  felt  on  the  side 
corresponding  to  the  swelling.  The  dimensions  and  outline  of  the 
swelling  can  best  be  estimated  by  bimanual  examination.  The 
lateral  vaginal  fornix,  and  often,  if  there  is  accompanying  perime- 
tritis, the  posterior  fornix,  are  depressed  by  the  exudation.  The 
thickening  may  extend  round  the  back  of  the  uterus  and  reach  the 
other  side,  or,  more  rarely,  descend  on  the  anterior  vaginal  wall, 
surrounding  the  bladder.  The  uterus  is  pushed  toward  the 
opposite  side.  Its  mobility  is  diminished,  and  may  be  almost 
entirely  lost,  if  the  exudation  extends  around  it.  Fixation  of  the 
uterus  is  not,  however,  so  marked  a  feature  in  pelvic  cellulitis  as 
in  pelvic  peritonitis,  and  its  mobility  is  more  quickly  restored.  If 
the  exudation  extends  to  the  iliac  fossa,  it  may  form  a  swelling 
reaching  several  inches  above  Poupart's  ligament,  which  is  readily 
felt  by  external  manipulation  only,  and  is  sometimes  visible  on 
inspection  of  the  abdomen.  The  tendency  to  spread  to  the  iliac 
fossa  is  much  greater  in  cellulitis  of  puerperal  origin  than  in  that 
which  arises  apart  from  delivery. 

If  suppuration  does  not  occur,  the  swelling  becomes  gradually 
harder  and  less  sensitive,  and  then  begins  to  diminish  from  absorp- 
tion. At  the  height  of  the  disease  it  feels  rounded  from  the  vagina ; 
but,  as  it  diminishes,  it  becomes  flatter  on  its  lower  surface,  and 
sometimes  concave  or  angular.  When  the  mass  has  been  absorbed, 
the  uterus  becomes  drawn  toward  the  affected  side  by  contraction 
of  fibroid  tissue.  The  uterus  may  regain  most  of  its  mobility.  It 
may   be   many   months  before    the    utmost   attainable   degree   of 


I024 


The  Practice  of   Midwifery. 


absorption  is  reached,  and  some  fibroid  thickening  may  remain 
permanently,  but  often,  after  six  or  eight  weeks,  the  swelling  has 
almost  entirely  disappeared.  Years  afterwards,  the  relic  of  the 
disease  may  be  felt  in  the  shape  of  a  fibrous  band,  generally 
starting  from  the  angle  of  a  cervical  laceration  outward  to  the 
pelvic  wall. 

If  suppuration  takes  place,  the  disease  is  protracted  for  many 
weeks,  hectic  fever  is  established,  and  there  is  loss  of  appetite,  and 
other  signs  of  pus  formation.     It  is  often  seven  or  eight  weeks 


Fig.  492. — Section  parallel  to  pelvic  brim,  a  little  above  the  level  of  the  internal 
OS  uteri,  showing  the  situation  of  induration  in  parametritis.  B,  bladder ; 
A  F  P,  anterior  fossa  of  peritoneum,  free  from  exudation;  P  F  P,  posterior 
fossa  of  peritoneum,  free  fiom  exudation;  u,  uterus  displaced  to  right; 
B  L,  left  broad  ligament  infiltrated  vi^ith  cellulitic  effusion  ;  E,  rectum. 


before  the  pus  is  discharged.  Some  authors  have  estimated  that 
suppuration  takes  place  in  more  than  half  the  cases  of  parametritis, 
but  probably  the  proportion  is  much  less  than  this,  if  all  slight  cases 
are  included.  Suppuration  is,  however,  more  frequent  in  parametritis 
than  in  perimetritis. 

The  most  characteristic  local  condition  produced  when  the 
thickening  is  due  to  perimetritis,  not  parametritis,  is  a  uniform 
board-like  induration  of  the  whole  roof  of  the  pelvis,  with  the  uterus 
firmly  fixed  in  its  centre  or  pushed  very  slightly  forward  by  lymph 
in  the  pouch  of  Douglas.  This  is  chiefly  met  with  in  cases  arising 
apart  from  parturition  or  abortion.  Peritonitis  may,  however,  form 
a  local  swelling  at  the  back,  front,  or  side  of  the  uterus,  from  a 


Puerperal  Fevers. 


1025 


matting  together  of  coils  of  intestine,  and  especially  in  one  or  both 
posterior  quarters  of  the  pelvis,  due  to  matting  of  the  tubes  and 


Fig.  493. — Death-rates  from  puerperal  fever  and  other  diseases  in  England  and 
Wales,  with  rainfall  at  Greenwich,  from  1881  to  1899.  KA.  Rainfall  at  Green- 
wich, inverted  curve.  P.F.  Puerperal  fever.  ER.  Erysipelas.  SEP.  Septi- 
caemia and  pyaemia.  SC.  Scarlatina.  RH.  Rheumatic  fever.  Each  vertical 
division  corresponds  to  20  per  cent. 

ovaries,  sometimes  with  distension  of  the  tubes.  If  such  a  swelling 
extends  at  the  same  time  far  above  the  brim,  not  toward  the  iliac 
fossa,  it  is  likely  to  be  the  result  of  peritonitis.  The  opening  of  an 
abscess  at  or  near  the  uml)ilicus  is  also  a  h'v^w  of  peritoneal  origin. 
M.  65 


I026  The  Practice  of   Midwifery. 

In  encysted  peritonitis  a  fluctuating  swelling  is  formed,  which  may 
resemble  a  cystic  tumour,  and  displaces  the  uterus  by  pressure. 
It  is  most  commonly  behind  the  uterus,  and  pushes  the  cervix 
forward. 

After  the  opening  of  an  abscess,  the  pain  is  generally  quickly 
relieved,  the  fever  subsides,  and  the  sinus  closes  in  a  short  time. 
Sometimes,  however,  if  there  is  deep  and  extensive  burrowing  of  pus, 
the  sinus  remains  long  open,  and  the  patient  may  eventually  die 
from  exhaustion.  This  is  more  likely  to  happen  with  an  abscess  of 
peritoneal  origin. 

Frequency.— It  will  be  seen  from  Fig.  485,  p.  1000,  that  in  Eng- 
land and  Wales,  up  to  1899,  puerperal  sepsis,  though  limited  to  one 
sex  and  a  particular  time  of  life,  still  caused  a  mortality  nearly  half 
as  much  again  as  that  of  erysipelas  in  both  sexes,  and  nearly  six 
times  as  great  as  that  of  all  other  forms  of  septicaemia  and  pysemia 
together.  But,  while  in  the  term  1855 — 1880  puerperal  sepsis 
shows  no  diminution,  but  rather  an  increase,  there  is  a  steady 
diminution  from  1881  to  1900,  with  the  exception  of  the  years  of 
special  rise,  1892,  1893.  In  London  the  improvement  is  as  great 
as  that  in  other  septic  diseases,  the  curve  beginning  at  46  per  cent, 
above  the  mean  and  ending  at  45  per  cent,  below  it  (Fig.  493, 
p.  1025).  In  England  and  Wales  the  improvement  is  not  so  great. 
The  curve  begins  at  12  per  cent,  above,  and  ends  at  only  20  j)er 
cent,  below,  the  mean  ;  and  at  a  mortality  of  62  per  million  living, 
compared  with  one  of  46  per  million  in  London.  In  England  and 
Wales,  however,  there  has  been  a  steady  improvement  during  the 
last  few  years,  and  while  in  1901  the  death-rate  from  puerperal  fever 
was  22*3  per  10,000  births  with  living  children,  it  has  fallen  to  14*8 
for  the  year  1908.  In  the  same  way  there  has  been  even  a  more 
marked  improvement  in  the  figures  for  London,  no  doubt  due  to  the 
fact  that  a  larger  proportion  of  the  confinements  in  this  city  are 
attended  by  medical  men  or  properly  trained  midwives. 

Diagnosis. — Any  elevation  of  temperature  much  above  100°  F. 
in  the  j)uerperal  woman,  if  not  accounted  for  by  some  independent 
condition,  such  as  inflammation  of  the  breasts,  constipation,  or 
nervous  disturbance,  should  raise  a  suspicion  as  to  the  commence- 
ment of  septic  disturbance,  although  many  such  elevations  prove  to 
be  evanescent.  The  rise  of  temperature  is  more  significant,  if 
accompanied  by  rigors  and  tenderness  of  the  uterus.  A  pulse  rapid 
in  proportion  to  tbe  temperature,  a  coated  or  dry  tongue,  headache 
and  vomiting,  are  also  signs  pointing  to  septicaemia.  If  the  progress 
of   involution   of  the  uterus   is   recorded   in    the    way    previously 


Puerperal   Fevers.  1027 

described,  a  check  in  the  rate  of  diminution,  especially  if  accompanied 
by  pyrexia,  is  very  valuable  as  an  early  sign  of  mischief.  It  may 
occur  both  in  saprsemia  and  septicaemia.  The  pain  due  to  com- 
mencing metritis  or  peritonitis  is  distinguished  from  after-pains  by  its 
continuous  character,  and  by  its  being  accompanied  by  tenderness, 
and  a  pulse  more  rapid  than  normal.  Distension  of  the  abdomen 
is  a  significant  symptom,  even  in  the  absence  of  pain  and  tenderness. 
Diminution  or  suppression  of  lochia  and  milk  generally  point  to 
developed  septic  inflammation,  especially  if  the  lochial  discharge  has 
previously  been  offensive. 

It  must  be  remembered  that  a  rise  of  temperature  during  the  first 
week  may  be  due  to  the  onset  of  some  acute  illness  independent  of 
the  puerperium.  The  conditions  most  likely  to  lead  to  error  in 
diagnosis  are  influenza,  typhoid  fever,  malaria  in  tropical  climates, 
and  the  onset  of  acute  miliary  tuberculosis.  I  have  met  with  a  case 
in  which  a  failure  to  recognise  that  a  puerperal  patient,  thought  to 
be  affected  by  septicaemia,  was  in  reality  suffering  from  typhoid 
fever,  led  to  a  disastrous  outbreak  of  that  disease  among  the  nurses 
of  the  institution  to  which  she  was  admitted. 

In  all  cases  a  careful  examination  of  the  genital  tract  should  be 
carried  out,  and  special  attention  paid  to  the  appearance  of  any  tears 
or  lesions  in  the  vulva  and  vagina.  A  bacteriological  examination 
should  be  made  of  the  contents  of  the  uterus  in  the  manner  described 
on  p.  1036. 

A  cultivation  should  also  be  made  from  the  blood  in  all  sus- 
pected cases  of  septic  infection,  and  a  differential  count  of  the  blood 
cells  undertaken. 

Prognosis. — Statistics  already  quoted  show  that,  if  slighter  and 
transient  forms  of  pyrexia  are  included,  in  which  modern  observa- 
tions show  the  presence  of  septic  organisms  within  the  uterus,  the 
general  prognosis  is  favourable,  and  the  mortality  not  more  than 
from  4  to  8  per  cent.  In  the  354  cases,  however,  reported  to  the 
Collective  Investigation  Committee  of  the  British  Medical  Associa- 
tion (1884),  which  were  cases  of  serious  forms  of  pyrexia  of  some 
duration,  with  temperatures  over  103°  or  104°  F.,  the  general 
mortality  was  47*4  per  cent.  This  high  mortality  cannot  have  been 
due  to  undue  activity  of  treatment,  for  curetting  of  the  uterus  was 
not  employed.  The  relative  mortality  of  some  of  the  principal  forms 
of  the  disease  has  already  been  mentioned.  The  danger  appears  to 
depend  mainly  upon  the  virulence  of  the  particular  infection 
concerned.  The  mortality  of  70*8  per  cent,  in  24  cases 
ascribed  to  infection  from  other  cases  of    puerperal   septicaemia, 

65—2 


I028  '  The  Practice  of   Midwifery. 

and  70*6  per  cent,  in  17  cases  ascribed  to  contagion  from 
erysipelas,  but  not  showing  any  erysipelatous  rash,  is  specially 
worthy  of  note.  It  agrees  with  experience  as  to  the  high  mortality 
when  a  series  of  cases  of  puerperal  sepsis  has  occurred  in  the 
practice  of  a  midwife  or  accoucheur.  When  the  condition  is  one 
merely  of  retention  of  lochia  or  of  putrid  endometritis  due  to 
portions  of  retained  placenta  or  membranes  the  outlook  is  usually 
favourable.  This  is  also  the  case  when  the  organism  present  is 
the  gonococcus.  In  cases  of  general  streptococcic  infection,  if  there 
are  definite  local  affections,  the  prognosis  is  favourable,  especially 
if  the  symptoms  are  limited  to  the  uterus,  if  there  is  no  excessive 
elevation  of  temperature  or  pulse,  no  distension  of  abdomen  or 
diarrhoea,  and  if  the  lochial  discharge  is  not  suppressed.  The 
earlier  the  onset  of  the  disease  after  delivery  the  worse  is  the 
j)rognosis,  and  it  is  still  worse  if  the  fever  commences  before 
delivery.  When  the  fever  commences  after  a  week  has  passed, 
tbe  prognosis  is  more  favourable.  The  complaint  is  then  more  likely 
to  turn  out  to  be  local  parametritis  without  general  septic  infection. 
The  gravest  symptoms  are  signs  of  general  peritonitis,  great 
rapidity  of  pulse,  very  high  temperature,  dry  tongue,  severe  vomit- 
ing, diarrhoea,  and  above  all  great  tjanpanitic  distension  of  abdomen. 
Diphtheritic  deposit  on  vaginal  ulcers,  or  in  the  throat,  is  an  un- 
favourable sign.  The  most  serious  complications  are  pneumonia  and 
pericarditis.  With  a  high  degree  of  pyrexia,  it  is  a  favourable  sign 
to  find  a  considerable  local  swelling  of  parametritis,  for  the  pyrexia 
need  not  then  be  due  to  the  more  serious  condition  of  general 
peritonitis,  or  to  general  septic  infection.  If  an  investigation  of 
the  blood  shows  that  the  number  of  leucocytes  is  50,000  or  more 
per  cubic  centimetre,  that  the  eosinophiles  are  absent  while  the 
neutrophiles  are  undergoing  degenerative  changes,  and  that  there 
is  a  marked  diminution  in  the  number  of  the  red  discs,  a  very 
unfavourable  prognosis  should  be  given.^ 

Prophylaxis.  The  most  important  points  in  prophylaxis  are — - 
(1)  to  guard  the  puerperal  woman  from  the  access  of  any  special 
infection  ;  (2)  to  prevent  the  retention  of  any  material  liable  to 
decompose  or  form  a  nidus  for  septic  micrococci ;  and  (3)  to  secure, 
as  far  as  possible,  that  the  woman  shall  be  in  the  best  possible 
condition  for  resisting  any  morbid  process,  and  that  no  unnecessary 
avenues  shall  be  left  open  for  absorption,  and  no  avoidable  injury 
done  to  the  tissues, 

1  Kownatzki,  Zentr.-ilbl.  f.  G.ynak.,  1906,  No.  43. 


Puerperal   Fevers.  1029 

The  first  thing,  in  point  of  time,  is  to  promote  the  health  of  the 
woman  before  delivery.  This,  however,  the  physician  may  not 
always  have  the  opportunity  of  carrying  out.  The  sanitary  con- 
ditions of  the  house  and  lying-in  room  are  of  special  importance. 
Care  should  be  taken  that  the  drains  are  in  order,  and  there  is  no 
access  of  sewer  gas,  or  ill-arranged  water-closet  or  sink  near  the 
room.  Ventilation  by  abundant  fresh  air  is  of  equal  importance. 
This  is  proved  by  the  fact  that  the  frequency  of  puerperal 
septicaemia  has  a  seasonal  variation  in  proportion  to  the  cold. 
The  mean  curve  of  mortality  has  a  maximum  in  January,  and  a 
minimum  period  from  the  middle  of  May  to  the  end  of  September. 
Ventilation  should  be  aided  by  an  open  fire  whenever  the  weather 
is  not  warm  enough  to  allow  open  windows.  The  utmost  cleanli- 
ness should  be  observed  in  the  lying-in  room,  and  all  soiled  linen 
at  once  removed. 

In  labour,  the  patient  should  not  be  allowed  to  become  exhausted 
by  undue  protraction,  and  timely  aid  by  forceps  should  be  given 
when  required.  On  the  other  hand,  it  is  of  at  least  equal  import- 
ance not  to  cause  unnecessary  lacerations  by  premature  or  hasty 
delivery  with  forceps  when  the  head  is  delayed  by  the  cervix  or 
vaginal  outlet.  No  rupture  of  the  perineum  should  be  allowed  to 
remain  without  the  application  of  sutures.  It  is  of  importance  to 
secure  a  firm  and  permanent  contraction  of  the  uterus,  that  there 
may  not  be  gaping  orifices  to  afford  ready  access  for  any  septic 
germs  to  reach  the  thrombi  in  the  vessels,  and  that  clots  may  not 
bs  allowed  to  remain  and  become  decomposed  within  the  uterine 
cavity.  It  has  been  recommended  to  administer,  as  a  routine 
practice  in  all  cases,  a  mixture  C(mtaining  quinine,  ergot,  and 
digitalis,  with  the  object  of  maintaining  uterine  contraction. 
This  does  not  seem  necessary  when  the  woman  is  strong  and 
the  uterus  active,  but  it  is  very  useful  whenever  there  is  any 
tendency  to  inertia.  The  plan  already  recommended  of  not 
letting  the  patient  remain  too  much  in  one  position,  and  allowing 
her  to  kneel  up  to  pass  water  after  two  days,  aids  the  escape 
of  the  lochial  discharge  and  the  expulsion  of  any  clots  from  the 
uterus. 

The  most  important  safeguards  consist  in  the  use  of  those  anti- 
septic precautions  during  labour  and  the  puerperal  state  which 
have  been  already  described  (see  pp.  291,  380),  especially  those 
which  are  designed  to  prevent  the  introduction  of  any  septic 
micro]>es  into  the  genital  canal. 

Direct  precautions  should  also  be  taken  against  any  possible 
conveyance   of   contagion    from   any  virulent    source.      No    nurse 


1030  The  Practice  of   Midwifery. 

should  be  allowed  to  be  in  attendance  who  has  recently  attended 
any  case  of  zymotic  disease,  puerperal  septicaemia,  erysipelas,  or  '.m 

even  any  doubtful  case  of  pyrexia  after  delivery.     All  unnecessary     •      ■ 
visitors  should  be  excluded  from   tbe  lying-in   room  during  the  " 

first  week,  especially  any  who  are  likely  to  have  been  in  contact 
with  any  zymotic  or  puerperal  contagion. 

In  family  practice  it  is  impossible,  as  a  rule,  for  the  practitioner 
to  give  up  midwifery  practice  whenever  he  has  cases  of  erysipelas 
or  zymotic  disease,  or  suppurating  wounds,  under  his  charge. 
That  contagion  is  but  rarely  carried  appears  to  be  proved  by 
the  comparative  rarity  of  actual  scarlatina  and  erysipelas  after 
delivery  in  proportion  to  the  whole  number  of  cases  of  severe 
puerperal  pyrexia,  especially  when  it  is  remembered  that  con- 
tagion may  be  received  in  many  other  ways  besides  that  of 
conveyance  by  the  accoucheur.  All  medical  men  should,  how- 
ever, take  the  most  careful  antiseptic  precautions  after  visiting 
cases  of  any  zymotic  aisease  before  attending  a  labour  or  visiting 
puerperal  patients.  Not  only  should  hands  be  washed  in  some 
effective  antiseptic  solution,  such  as  in  rectified  spirit  and  then  in 
perchloride  of  mercury  (1  in  1,000),  but  clothes  should  be  changed, 
and  the  longest  possible  interval  allowed  for  disinfection  by 
fresh  air. 

It  should  be  remembered  that,  next  to  puerperal  fever  itself,  the 
most  dangerous  source  of  infection  is  phlegmonous  erysipelas 
with  a  discharging  or  suppurating  wound.  Any  practitioner 
attending  to  such  a  wound  would  do  well  to  take  as  careful  extra 
precautions  as  if  he  were  attending  a  case  of  puerperal  septicaemia. 
In  all  these  conditions  the  practice  should  be  made  of  wearing 
steriHsed  rubber  gloves  when  attending  a  lying-in  patient. 

It  is  a  still  more  important  question  what  precautions  are 
necessary  when  a  medical  man  has  a  case  of  puerperal  pyrexia  of 
any  form  under  his  charge,  and  whether  it  is  his  duty,  under 
these  circumstances,  to  give  up  midwifery  practice.  It  is  as 
undesirable  to  impose  restrictions  which  are  not  necessary  as  to 
omit  any  which  are  really  called  for.  A  practitioner  may  be 
tempted  to  omit  local  treatment,  which  is  of  importance  for  the 
recovery  of  his  patient,  if  he  believes  that  his  undertaking  it 
renders  it  necessary  for  him  to  give  up  the  greater  part  of  his 
practice.  Again,  under  similar  circumstances,  he  may  be  reluctant 
to  admit  to  his  own  mind,  when  diagnosis  is  doubtful,  that  any 
given  case  of  puerperal  pyrexia  is  of  septicsemic  character,  and 
liable  to  become  the  source  of  infection. 

Puerperal    septicaemia    does,   however,   appear  to   be  the  most 


Puerperal   Fevers.  1031 

dangerous  source  of  contagion  of  all,  as  is  proved  by  those 
unfortunate  instances  in  which  a  practitioner  has  a  series  of 
severe  or  fatal  cases  in  his  practice,  terminated  only  by  his  giving 
up  midwifery  for  a  considerable  time.  The  utmost  precaution  is 
therefore  necessary.  When  contagion  has  been  conveyed  by  the 
accoucheur,  it  has  frequently  happened  that  the  victims  have 
been  women  delivered  within  two  or  three  days  after  the  one  who 
was  the  source  of  the  contagion,  and  the  mischief  has  thus  been 
done  before  the  physician  had  become  aware  that  the  disease  was 
of  a  nature  requiring  special  precaution.  It  would  be  impossible 
for  every  medical  man  to  give  up  midwifery  practice  whenever  a 
patient  had  a  rise  of  temjDerature  after  delivery.  The  first  and 
most  essential  requisite,  therefore,  is  to  regard  all  cases  of  puerperal 
pyrexia,  even  of  the  slightest  kinds,  as  suspicious,  and  to  adopt 
the  most  scrupulous  antiseptic  precautions  in  attending  them. 

It  is  above  all  important  to  preserve  the  clothes,  and  especially 
the  coat,  from  becoming  contaminated.  The  hands  may  probably 
be  made  safe  by  the  thorough  use  of  antiseptics  and  the  wearing  of 
sterilised  rubber  gloves,  but  the  clothes  cannot  be  so  unless  they 
are  disinfected  by  heat.  Fumigation  may  perhaps  destroy  germs 
conveyed  in  the  form  of  dust  and  settling  on  the  surface,  but  cannot 
be  relied  upon  if  there  has  been  closer  contact  with  infecting 
material,  or  if  blood  or  discharge  has  soaked  into  the  cloth.  Even 
if  the  clothes  are  changed,  it  is  easy  to  understand  that,  in  the  very 
act  of  changing,  contagion  may  be  conveyed  by  the  hands  from  one 
suit  to  another.  When  physicians  have  given  up  midwifery  for 
several  weeks  and  yet  have  had  a  recurrence  of  septicaemia  on 
returning  to  it,  it  is  probable  that,  in  most  cases,  the  contagion  has 
lingered  in  clothes.  It  is  obvious  that  gloves  especially,  if  once 
infected,  would  readily  again  convey  contagion  to  the  hands.  Some- 
times, indeed,  there  may  have  been  something  peculiar  to  the 
individual,  as  in  the  case  of  those  who  have  themselves  any  ailment 
associated  with  a  purulent  discharge. 

In  any  case,  therefore,  of  puerperal  pyrexia,  even  if  regarded  as 
not  serious,  the  physician  should  keep  his  clothes  from  contact  with 
the  patient  or  the  bed-clothes.  If  he  makes  any  vaginal  examina- 
tion, he  should  take  off  his  coat,  roll  up  his  shirt-sleeve,  and  put  on 
an  overall  kept  for  that  particular  case.  After  touching  the  patient, 
or  anything  connected  with  her,  he  should  constantly  bear  in  mind 
that  his  hand  is  contaminated,  and  avoid  touching  his  own  clothes, 
bag,  or  instruments  with  it  until  it  has  been  disinfected.  A 
thermometer  or  stethoscope  should  be  disinfected  with  equal  care. 
After  disinfecting  his  hands,  he  should  avoid  even  shaking  hands 


1032  The  Practice  of   Midwifery. 

with  the  patient  on  leaving.  The  only  effectual  mode  of  disinfecting 
clothes  is  exposure  to  steam  at  a  high  pressure.  If  a  physician  has 
to  attend  a  confinement  after  recent  contact  with  a  case  likely  to 
convey  virulent  infection,  it  is  a  safeguard,  in  addition  to  the 
ordinary  antiseptic  precautions,  to  wear  a  sterilised  overall,  as  for 
an  abdominal  section,  and  indiarubber  gloves,  sterilised  by  boiling 
water. 

When  a  case  of  puerperal  pyrexia  is  likely  to  be  specially  con- 
tagious, it  is  desirable  that  the  attendant  should  give  up  midwifery 
practice  for  a  time.  Much  yet  has  to  be  learnt  about  the  differences 
in  contagious  character  of  different  forms  of  the  disease.  But  it 
appears  to  be  clearly  established,  that  the  most  contagious  are 
very  severe  or  fatal  forms  of  it  (see  p.  1005),  and  also  those  which 
are  themselves  derived  from  virulent  conveyed  contagion.  My  own 
belief  is  that  antiseptic  precautions  carried  out  as  described  above 
are  an  adequate  security.  But  the  fact  remains  that  contagion  is 
sometimes  conveyed,  and  the  occurrence  of  the  first  case  of 
septicaemia  generally  implies  some  deficiency  in  antiseptic  method. 
There  is  also  another  consideration  to  be  taken  into  account. 
If  it  is  known  that  a  practitioner  has  lost  a  patient  after  delivery, 
and  any  other  of  his  patients  suffers  from  pyrexia,  he  is  likely  to  be 
accused  of  carrying  contagion,  even  though  there  may  be,  in  reality, 
no  connection  between  the  two  cases.  Hence  if  a  practitioner  has 
a  fatal  case  of  puerperal  septicaemia,  or  one  likely  to  prove  fatal,  he 
will  do  wisely  to  give  up  midwifery  practice  up  to  at  least  a  week 
after  the  cessation  of  attendance.  A  bath  should  be  taken  before 
he  again  attends  labour,  the  clothes  disinfected,  if  possible,  by 
steam,  and  a  different  suit  worn.  If  there  is  reason  to  think  that 
contagion  has  actually  been  conveyed  to  any  other  patient,  it  is 
obvious  that  the  antiseptic  precautions  taken  have  not  proved 
adequate.  It  is  then  imjDerative  to  give  up  midwifery  practice,  and 
in  this  case  it  is  well  to  make  the  quarantine  longer — as  much  as 
two  or  three  weeks. 

By  the  rules  of  the  Central  Midwives'  Board,  whenever  a  midwife 
has  been  in  attendance  upon  a  patient  suffering  from  j^uerperal 
fever,  or  from  any  ihness  sujjposed  to  be  infectious,  she  must  dis- 
infect herself  and  all  her  instruments  and  other  appliances  to  the 
satisfaction  of  the  local  sanitary  authority,  and  must  have  her 
clothing  thoroughly  disinfected  before  going  to  another  labour. 

Prophylaxis  in  Lying-in  Hospitals. — In  former  years  the  mor- 
tality due  to  puerperal  septicaemia  in  lying-in  hospitals  was  so 
great,  that  many  authorities  considered  that  such  hosj^itals  were 
an  injury,  rather  than  an  advantage,  to  the  community.     While 


Puerperal   Fevers.  i033 

in  such  institutions  as  the  outdoor  lying-in  charities  of  London 
hospitals,  and  the  Koyal  Maternity  Charity,  the  total  maternal 
mortality  generally  did  not  exceed  one-half  per  cent.,  in  lying-in 
hospitals,  apart  from  any  epidemic,  the  mortality  almost  always 
exceeded  1  per  cent.,  and  often  reached  or  exceeded  2  per  cent. 

The  transformation  by  which  lying-in  hospitals,  not  only  in 
Britain,  but  on  the  Continent,  have  now  been  changed  from 
the  most  dangerous  into  the  safest  places  for  a  lying-in  woman, 
was  first  obtained  by  the  introduction  of  the  use  of  perchloride  of 
mercury  as  an  antiseptic.  Taking  the  General  Lying-in  Hospital 
as  an  example,  the  death-rate  was  reduced  from  10  or  more  to 
less  than  4  per  1,000 ;  the  death-rate  from  septicaemia  or  pelvic 
inflammation  to  1"5  per  1,000 ;  and  cases  of  septic  pyrexia,  includ- 
ing slight  and  transient  ones,  from  40"0  to  2'5  per  cent.  In  the 
ten  years  ending  1904  5,227  women  were  delivered  in  this  hospital 
with  only  three  deaths  from  sepsis,  or  a  death-rate  of  0*5  per  1,000  ; 
while  in  the  Eotunda  Hospital  from  1890  to  1896  the  mortality  from 
sepsis  was  only  I'l  per  1,000. 

These  results  in  the  General  Lying-in  Hospital  were  obtained 
by  the  use  of  antiseptic  agents.  Perchloride  of  mercury,  1  in 
1,000,  was  used  to  disinfect  hands  and  non-metallic  instru- 
ments by  every  one  who  touched  the  patients.  A  douche  of  per- 
chloride of  mercury,  1  in  2,000,  was  used  after  labour.  The  same 
antiseptic  was  used  for  washing  and  douching  the  patient  regularly 
throughout  the  puerpery,  for  the  first  three  days  of  a  strength  of 
1  in  2,000,  afterwards  1  in  4,000.  Horsehair  mattresses  were 
employed,  and  were  disinfected  by  heat  only  when  an  unfavourable 
case  had  occurred.  A  separate  irrigator  was  provided  for  each  bed, 
having  a  vaginal  tube  of  glass. 

It  is  possible  that  some  of  the  modern  non-poisonous  antiseptics 
may  prove  as  efficacious  as  mercury,  but  they  have  not  yet  been 
subjected  to  so  prolonged  a  trial.  Lysol  may  be  used  of  a  strength 
of  1  in  200  for  vaginal  douches,  chinosol  1  in  300  or  1  in  500, 
cyllin  1  in  100.  It  appears  to  be  safest  to  retain  the  mercurial 
solution  for  disinfection  of  hands.  Of  late  the  tendency  at 
lying-in  hospitals  is  to  disuse  routine  douches  in  normal  cases, 
but,  in  their  absence,  the  vulva  should  be  protected  by  a  sterilised 
or  antiseptic  occlusion  bandage  after  delivery,  and  should  be 
carefully  cleansed  and  disinfected  before  labour.  At  the  New 
York  Lying-in  Hospital  douches  have  been  abandoned,  without 
impairment  of  results.  But  the  vulva  is  kej)t  covered  by  antisej^tic 
pads  soaked  in  creolin,  1  in  100,  covered  with  oiled  muslin,  and 
changed  every  six  hours,  or  whenever  the  patient  passes  urine  or 


I034  The  Practice  of   Midwifery. 

faeces.     At  the  Eotunda  Hospital,  Dublin,  routine  douches  are  also 
disused,  and  the  results  remain  excellent. 

Treatment. — Local  Treatment. — The  first  question  to  be  con- 
sidered is  that  of  local  treatment,  to  prevent,  if  possible,  the 
entrance  of  any  more  septic  germs  or  poisonous  material  into 
the  circulation  or  tissues. 

First,  a  careful  examination  should  be  made  of  vulva,  vagina  and 
cervix,  with  a  view  to  determine  the  probable  site  of  absorption, 
and  direct  local  treatment  accordingly.  If  stitches  have  been 
applied  to  a  ruptured  perineum  and  union  has  evidently  failed,  it 
may  be  desirable  to  remove  the  stitches.  On  the  other  hand,  an 
unstitched  rupture  may  be  united  with  sutures  with  advantage, 
even  up  to  a  week  after  delivery,  if  the  surface  is  not  too 
unhealthy.  If  any  "  puerperal  ulcers "  or  sloughy  granulating 
surfaces  are  discovered,  the}^  should  be  painted  over  with  equal 
parts  of  tinct.  ferri  perchlor.  and  tinct.  iodi,  or  with  solution  of 
nitrate  of  silver  (gr.  xx.  ad  5].),  or  a  solution  of  carbolic  acid 
in  glycerine  (gr.  x.  ad  5].).  If  there  is  any  diphtheritic  or 
pseudo-diphtheritic  deposit,  the  application  should  be  repeated 
till  it  disappears. 

In  the  absence  of  any  other  probable  situation,  the  placental  site 
will  be  the  most  likely  seat  of  absorption  ;  and  this  conclusion  is 
confirmed  if  the  uterus  is  tender  and  its  involution  deficient.  In 
some  cases  there  may  be  reason  to  suppose  that  more  than  one  site 
of  absorption  exists. 

In  any  case  of  pyrexia,  vaginal  irrigation  should  be  adopted,  if 
it  has  not  previously  been  carried  out,  the  irrigation  being  used  at 
least  twice  a  day.  One  of  the  mo.-.t  efiicacious  antiseptics  should 
be  used,  such  as  perchloride  or  iodide  of  mercury,  1  in  4,000.  If 
the  patient  should  be  suffering  from  diarrhoea,  lysol,  1  in  100, 
chinosol,  1  in  300,  or  cyllin,  1  in  100,  may  be  used  instead  of  the 
mercurial  solution.  If  there  has  been  any  offensive  discharge,  a 
pessary  containing  15  or  20  grains  of  iodoform  may  be  introduced 
into  the  vagina  after  each  irrigation.-^ 

If  it  is  diagnosed  that  the  placental  site  is  the  seat  of  absorption, 
the  first  question  to  decide  is  whether  to  explore  the  cavity  of  the 
uterus.  In  cases  of  only  moderate  pyrexia,  and  when  the  medical 
attendant  from  a  careful  examination  of  the  placenta  and  mem- 
branes after  their  expulsion  has  satisfied  himself  that  there  is  no 

1  At  Vienna  iodoform  rods  are  used  according  to  the  following  formula  : — iodoform 
gr.  100  ;  gum  arabic,  glycerine,  and  starch,  each  10  grains.  One  of  these  is  introduced 
into  the  uterine  cavity  after  every  difficult  labour. 


Puerperal   Fevers. 


1035 


possibility  of  any  portion  of  either  of  these  structures  being 
retained  m  utero,  it  may  be  sufficient  first  to  try  the  effect  of  irrigating 
the  uterine  cavity  with  an  antiseptic  such  as  iodide  or  perchloride 
of  mercury,  1  in  6,000  to  8,000.  If  the  poisonous  effect  of  mercury 
is  feared,  lysol,  1  in  100,  tinct.  iod.,  5ij.  ad  Oj.,  or  chinosol,  1  in  300, 
or  cyllin  emulsion,  1  in  200,  may  be  used.  Whitridge  Williams 
uses  only  normal  saline  solution,  others  recommend  alcohol  50  per 
cent.  An  irrigator  should  be  used,  and  care  should  be  taken  to 
avoid  introducing  air,  by  seeing  that  the  delivery  tube  is  filled  with 
the  solution  before  introducing  it,  and  by  stopping  the  flow  before 


Fig.  494. — Uterus  with  a  portion  of  retained  placenta,  from  a  patient  dying 
of  septicEemia,  who  had  an  attack  of  post  partum  haemorrhage.  (Univ. 
Coll.  Hosp.  Med.  School  Mus.). 


the  reservoir  is  nearly  empty.  The  vagina  should  first  be  washed 
out,  lest  any  septic  microbes  should  be  carried  by  the  tube  from  the 
vagina  into  the  uterus.  The  best  tube  for  irrigating  the  uterus  is 
Budin's  double-action  catheter  of  glass,  celluloid  or  metal ;  and 
care  should  be  taken  that  the  end  of  the  tube  is  passed  quite  up  to 
the  fundus.  This  can  generally  be  done  most  easily  with  the 
patient  in  the  lateral  position,  with  the  hips  over  the  edge  of  the 
bed,  and  a  mackintosh  to  carry  the  fluid  down  into  a  foot-pan. 
Before  the  irrigation  a  specimen  of  secretion  should  always  be 
obtained  from  within  the  cervix  by  a  sterilised  swab,  and  tested 
both   by  immediate   staining  of  a  cover  glass  preparation  and   by 


1036  The  Practice  of   Midwifery. 

cultivation,  A  still  better  plan  is  to  suck  up  the  uterine  secretion 
into  a  sterilised  glass  tube  having  a  suitable  curve,  by  means  of  a 
syringe  attached  to  it  by  a  piece  of  rubber  tubing,  and  then  close 
the  ends  with  sealing-wax.  The  patient  is  placed  in  the  lateral  or 
semi-prone  position,  the  cervix  exposed  by  a  Sim's  speculum,  and 
its  vaginal  portion  carefully  cleansed  by  a  swab  of  sterilised  cotton. 
The  glass  tube  is  then  passed  as  far  as  possible  into  the  uterine 
cavity. 

If  after  this  the  symptoms  are  not  improved  within  twenty-four 
hours,  or  in  any  case  where  there  is  the  least  possiblity  of  a  portion 
of  the  membranes  or  placenta  having  been  left  in  utero,  the  interior 
of  the  uterus  should  be  explored  at  once  with  the  finger.  The 
same  should  be  done  in  all  cases  without  delay  or  preliminary 
treatment,  if  the  first  rise  of  temperature  is  to  a  high  point,  such 
as  103°  or  more,  or  if  there  has  been  an  adherent  placenta.  Within 
the  first  week  after  delivery  the  cervix  will  generally  allow  the 
finger  to  pass.  In  cases  of  pyrexia  arising  later,  it  might  be 
necessary  to  dilate  first  with  Hegar's  dilators.  An  anaesthetic  is 
given,  the  gloved  finger  passed  to  the  fundus,  the  whole  cavity  of 
the  uterus,  especially  the  placental  site,  explored,  and  any  adherent 
placental  tissue  or  clots  or  shreddy  decidua  that  may  be  found 
scraped  away  and  removed.  The  uterus  is  then  washed  out  with 
a  weak  antiseptic  solution,  boiled  water,  or  normal  saline  solution. 
If  shreddy  tissue  or  offensive  material  has  been  found,  the  irriga- 
tion of  the  uterus  should  be  repeated  once  a  day  for  several  days, 
or  so  long  as  any  shreds  are  washed  away,  especially  if  the  lochial 
discharge,  by  which  the  decidual  fragments  are  generally  washed 
out  from  the  uterus,  is  early  suppressed.  A  rod  containing  iodoform 
(see  p.  1034)  may  be  introduced  after  each  irrigation.  If  the  interior 
is  found  quite  smooth  and  the  pyrexia  is  attributed  to  streptococcic 
infection,  it  is  better  to  leave  the  cavity  alone  after  the  first  irriga- 
tion, since  the  streptococci  will  be  multiplying  in  the  uterine  wall 
and  cannot  be  reached  by  the  lotion.  Repeated  irrigations  are 
more  likely  to  be  beneficial  if  bacteria  of  decomposition  or  staphylo- 
cocci, not  streptococci,  are  found  in  the  uterine  secretion. 

Some  authorities  recommend  the  use  of  the  curette  instead  of  the 
finger.^  The  curette  may  be  used  for  two  different  objects,  either 
as  a  substitute  for  the  finger  to  remove  adherent  shreds,  or  with 
the  view  of  removing  the  whole  of  the  endometrium  in  which  the 
streptococci  are  present.  While  general  curetting  of  the  endome- 
trium   has    sometimes    resulted  in  a    striking  improvement,  it  is 

1  Knyvett  Gordon,  Jouin.  Obst.  and  Gyn.  Brit.  Emp.,  1908,  Vol.  XIV.,  No.  4, 
p,  257. 


Puerperal   Fevers.  1037 

capable  of  doing  great  harm.  There  seems  to  be  only  a  remote 
possibility  that  the  whole  of  the  microbes  could  be  removed,  and 
there  is  evidently  a  risk  that,  if  a  barrier  of  leucocytes  has  been 
formed  against  the  streptococci,  fresh  avenues  of  absorption  would 
be  opened  up  by  the  curette.  While  opinions  widely  differ,  the 
prevalent  view  apj^ears  to  be  that  general  curetting  as  a  routine 
treatment  more  often  does  harm  than  good  and  increases  the 
average  mortality.  If  undertaken  at  all,  it  should  be  done  before 
there  is  any  sign  of  sepsis  extending  beyond  the  uterus.  A.fter- 
wards  the  cavity  of  the  uterus  may  be  plugged  with  moist  iodoform 
gauze  10  per  cent,  for  twenty-four  hours,  both  for  the  arrest  of 
haemorrhage,  and  for  the  destruction  of  any  microbes  which  may 
remain,  or  it  may  be  swabbed  out  at  the  time  with  pure  lysol 
or  izal. 

In  the  opinion  of  the  author  the  finger  is  better  as  a  rule  than 
the  curette  for  the  removal  of  placental  tissue  or  shreds,  unless 
the  former  is  very  firmly  adherent ;  and  the  curette  should  only  be 
used  in  the  exceptional  cases  in  which  placental  tissue  or  shreds 
cannot  be  satisfactorily  removed  by  the  finger.  The  best  form  of 
curette  is  a  blunt  irrigating  curette  of  rather  large  size  attached  to 
an  irrigator.  By  means  of  this  a  stream  of  hot  antiseptic  solution 
at  115°  F.  is  poured  through  the  stem  of  the  curette  during  the 
operation,  and  tends  to  check  haemorrhage  as  well  as  to  wash  away 
debris.  If  the  shreds  cannot  be  detached  witli  this,  a  sharp  curette 
may  be  used  with  the  greatest  caution  and  the  removal  completed 
by  brushing  out  the  uterus  with  a  brush  curette,  the  so-called 
ecouvillonage  of  French  authors. 

Peritonitis  may  be  treated  locally  by  hot  fomentations,  covered 
by  oiled  silk,  or  by  cold.  Turpentine  fomentations  at  the  outset 
sometimes  give  comfort.  For  the  relief  of  tympanitic  distension  of 
the  abdomen,  when  this  is  very  extreme,  the  effect  of  passing  a 
long  rectal  tube,  and  of  giving  turpentine  enemata,  may  be  tried. 

Diet. — Much  depends  upon  supporting  the  strength  by  liquid 
nourishment  given  in  small  quantities  at  short  intervals.  As  a 
rule  the  interval  should  not  be  more  than  two  hours.  The  chief 
reliance  should  be  placed  upon  milk,  but  yolks  of  eggs  beaten  up 
with  milk,  beef-tea,  and  meat  jelly  may  also  be  given.  Brand's 
essence  of  meat  is  often  retained  when  other  food  is  vomited.  If 
milk  is  vomited  in  curds,  barley-water  should  be  mixed  with  it. 
If  there  is  diarrhcea,  beef-tea  should  be  avoided,  and  the  milk 
should  l>e  given  with  lime-water.  Alcohol  is  of  use,  as  tending  to 
lower  the  temperature,  and  having  also  probably,  in  some  degree, 
an  antiseptic  influence.     Two  or  three  teaspoonfnls  of  brandy  may 


1038  The  Practice  of   Midwifery. 

be  given  every  hour,  beaten  up  with  egg,  and  an  equal  quantity  of 
water.  Iced  champagne  is  sometimes  found  to  relieve  vomiting. 
In  severe  cases,  when  the  pulse  becomes  very  rapid  and  feeble,  the 
quantity  of  brandy  may  be  increased  up  to  eight  or  twelve  ounces  in 
the  twenty-four  hours.  If  there  is  so  much  vomiting  as  to  prevent 
the  retention  of  a  sufficient  amount  of  nourishment,  nutrient 
enemata  should  be  used.  The  formula  given  at  p.  459  may  be 
used,  with  the  addition  of  an  ounce  of  brandy.  If  there  is  diarrhoea, 
twenty  minims  of  tincture  of  opium  may  be  added.  Forty  grains 
of  oxide  of  bismuth  may  also  be  added. 

Medicinal  Treatment. — The  drugs  most  to  be  relied  upon  are 
quinine  and  strychnine.  A  ten-grain  dose  of  the  former  may  be 
given  at  the  outset,  when  pyrexia  is  high,  and  then  five  grains 
every  three  or  four  hours.  When  the  fever  is  continuous,  and  is 
not  controlled  by  this  means,  a  dose  of  twenty  grains  twice  a  day 
is  sometimes  more  effectual.  Large  doses  of  quinine  are  often 
better  tolerated  when  given,  not  in  an  acid  solution,  but  as  a  simple 
powder  in  water  or  in  a  mucilaginous  mixture  with  fifteen  grains  of 
subnitrate  of  bismuth  and  five  grains  of  bicarbonate  of  soda. 

When  there  is  peritonitis,  opium  or  morphia  should  be  given  in 
sufficient  quantity  to  control  the  pain.  When  pain  is  severe,  large 
quantities  are  often  well  tolerated,  and  aj)pear  to  be  beneficial.  A 
subcutaneous  injection  of  a  quarter  or  a  third  of  a  grain  of  acetate 
of  morphia  may  be  given  at  the  outset,  and  then  some  Battley's 
liquor  opii  sedativus  may  be  added  to  the  quinine.  In  the  case  of 
vomiting,  the  sedative  may  be  injected  by  the  rectum  or  subcutane- 
ously.  In  prolonged  cases  of  fever,  and  those  which  assume  the 
pyaemic  form,  the  tincture  of  peichloride  of  iron,  in  addition  to,  or 
in  substitution  for,  the  quinine,  is  often  of  great  value. 

The  result  of  giving  purgatives  as  evacuants  has  been  highly 
spoken  of  by  some  authorities,  but  there  is  a  risk  of  setting  up 
diarrhoea,  which  is  always  an  unfavourable  symptom.  If  there  is 
constipation  at  the  outset  of  pyrexia,  and  no  very  acute  peritonitis, 
or  sign  of  severe  septic  affection,  three  or  four  grains  of  calomel 
may  be  given.  This  is  often  followed  by  a  fall  of  temperature. 
Diarrhoea  should  not  be  stopped  too  quickly,  if  moderate  in  amount, 
since  some  of  the  poison  may  be  carried  off  in  the  evacuations.  If 
necessary,  opium  may  be  given  by  the  mouth  or  rectum.  Tincture 
of  perchloride  of  iron. is  of  use  in  checking  diarrhoea,  if  tolerated  by 
the  stomach. 

Antistreptococcic  Serum. — Anti-streptococcic  serum  ^  has  not  yet 

1  Aronsohn,    Berl.    Klin.   Wochenschr.,    1902    and    1903  ;    Bumm,    Berl.    Klin. 
Wochenschr.,  1904,  No.  44  ;  Bordet,  Ann.  de  I'lnstit.  Pasteur,  Paris,  Vols.  IX.  to  XVIII. 


Puerperal   Fevers.  1039 

proved  so  successful  as  anti-diphtheritic  serum.  It  has  been  found 
that  one  variety  of  streptococcus  does  not  give  immunity  against 
the  effects  of  another.  Attempts  have  been  made  accordingly  to 
obtain  a  polyvalent  serum,  and  it  is  possible  that  in  time  one  more 
effective  for  puerperal  septicsemia  may  yet  be  procured.  The 
manner  in  which  the  anti-streptococcic  serum  a,cts  is  at  present 
unknown.  There  is  little  reliable  evidence  that  it  possesses  any 
bactericidal  action,  nor  are  there  any  facts  to  indicate  that  it  has  an 
antitoxic  action.  It  has  been  suggested  that  it  neutralises  the 
repellent  influence  exercised  by  streptococci  upon  leucocytes.  In 
this  connection  the  interesting  observation  has  been  made  that 
some  hours  after  inoculation  there  occurs  a  sudden  local  increase  of 
leucocytes.  It  is  quite  certain  that  an  active  anti-streptococcic 
serum  can  be  obtained,  and  the  most  probable  explanation  of  its 
action  is  that  which  regards  its  effect  upon  leucocytes  as  the 
important  factor.  For  the  present,  if  one  variety  of  serum  does 
not  seem  to  be  beneficial,  another  should  be  tried.  To  get  the  full 
effect,  it  appears  to  be  necessary  to  inject  as  much  as  10  c.c.  at  a 
time,  and  to  repeat  the  injections  as  much  as  twice  a  day.  A  first  dose 
may  be  given  of  20  c.c,  half  of  it  intravenously  ;  and  in  severe  cases, 
or  those  progressing  unfavourably,  as  much  as  60  c.c.  may  be 
given  daily.  In  some  cases,  this  treatment,  when  employed  early 
enough,  with  a  fresh  serum,  has  been  quickly  followed  by  improve- 
ment, and  recovery  has  resulted.  In  others  it  appears  to  cause 
temporary  improvement,  and  to  prolong  the  course  of  the  disease, 
although  the  fatal  result  is  not  averted.  When  there  is  purulent 
peritonitis,  or  any  considerable  formation  of  pus  elsewhere,  it  can 
hardly  be  expected  that  the  serum  can  check  the  growth  of  the 
micrococci,  although  it  is  possible  that  it  may  retard  the  spread  of 
the  organisms  from  the  point  of  inoculation  to  the  body  generally. 

The  cases  in  which  the  serum  should  be  tried  are  those  in  which 
the  presence  of  streptococci  has  been  verified  in  the  uterus  or  in 
the  blood,  and  cases  which  are  very  severe  and  likely  to  prove  fatal, 
since  in  these  there  is  a  strong  probability  that  the  streptococcus 
is  the  chief  microbe  concerned.  It  may  also  be  given  tentatively 
in  any  case  in  which  local  treatment  does  not  quickly  lead  to 
improvement,  pending  the  result  of  bacteriological  examination. 

A  syringe  with  asbestos  piston,  holding  10  c.c,  is  used  for 
injection,  as  in  the  case  of  anti-diphtheritic  serum,  and  syringe 
and  skin  should  be  carefully  sterilised.  The  injections  should  be 
made  in  the  loin  or  in  the  abdomen,  not  far  from  the  pelvis,  or 
into  one  of  the  veins  at  the  bend  of  the  elbow.  Occasionally  the 
injections  are  followed  by  urticarial  or  erythematous  eruptions  or 


1040  The  Practice  of   Midwifery. 

pains  in  the  bones,  and  it  will  be  necessary  to  var}^  the  site,  if 
many  injections  are  made. 

Vaccine. — Although  the  conditions  in  most  cases  of  pueri3eral 
infection  do  not  correspond  to  those  laid  down  by  Sir  A.  E.  Wright, 
as  suitable  for  treatment  by  vaccines,  namely,  "where  we  have  to 
deal  with  localised  bacterial  invasions  associated  with  inflammation 
at  the  site  of  inoculation,"  yet  there  are  some  cases  of  infection 
especially  with  the  staphylococcus  to  which  this  method  of  treat- 
ment may  well  be  applied,  and  there  seems  no  reason  why  in 
these  cases  good  should  not  result  from  the  use  of  a  vaccine 
derived  from  the  organism  present.  The  vaccine  should  be  freshly 
prepared,  and  a  dose  of  2'5  to  5  millions  of  dead  bacteria  given. 
The  effect  should  be  determined  by  observations  on  the  opsonic 
index,  but  for  clinical  purposes  the  temperature  and  pulse  form  a 
sufficient  guide,  a  high  temperature  and  rapid  palse  corresponding 
to  a  low  opsonic  index.  For  the  purpose  of  assisting  the  elimina- 
tion of  the  toxins  by  the  kidneys  and  diluting  them  in  the  blood 
and  the  tissues  large  intra-venous  or  subcutaneous  injections  of 
normal  saline  fluid  may  be  tried.  It  is  most  convenient  to  make  the 
injections  subcutaneously  under  the  mammte  or  into  the  tissues  of 
the  flank  or  axilla.  Half  a  pint  of  normal  saline  fluid  may  be 
injected  under  each  breast  daily.  The  beneficial  results  obtained 
by  continuous  proctoclj^sis  in  many  cases  of  acute  septic  peritonitis 
suggest  that  this  method  may  prove  of  value  in  cases  of  acute 
septicirBmia.  It  has  the  advantage  over  the  subcutaneous  injec- 
tions of  being  quite  painless,  and  it  can  be  carried  on  more 
continuously.  One  of  the  various  apparatuses,  which  can  now  be 
obtained  for  the  purpose,  should  be  employed,  and  the  injection 
continued  for  several  hours  each  day.  Care  must  be  taken  in  cases 
where  the  heart  is  acting  feebly  that  the  use  of  saline  injections 
does  not  lead  to  increase  in  the  amount  of  oedema  of  the  tissues. 
Glucose,  valuable  for  its  nutritive  properties,  may  be  combined 
with  the  rectal  injections  or,  in  a  strength  of  5  per  cent.,  which  is 
isotonic  with  the  blood,  with  the  intra-venous  injections  of  salt 
solution. 

In  an  attempt  to  destroy  the  organisms  circulating  in  the  blood 
and  at  the  same  time  to  assist  the  body  by  producing  a  condition  of 
leucocytosis  various  metals  have  been  employed.  Crede's^  oint- 
ment is  an  example  of  this  kind  ;  it  contains  15  per  cent,  of 
collargol  or  colloid  silver,  and  is  rubbed  into  the  thigh  once  or 
twice   daily   in   doses   of  15  to   45  grains.     It  is   said  to  have  a 

1  Crede,  Arch.  f.  Klin.  Chir ,  1903,  Bd.  69,  p.  225. 


Puerperal   Fevers.  1041 

bactericidal  action  upon  the  organisms  with  which  it  comes  into 
contact  and  to  produce  leucocytosis.  For  the  same  purpose  a 
2  per  cent,  solution  of  collargol  can  be  used  made  up  with  normal 
salt  solution,  and  5  to  15  cc.  injected  into  one  of  the  veins  of  the 
arm  once  a  day. 

Collargol  may  also  be  administered  by  the  mouth  in  doses  of 
J  to  2  grains,  or  combined  with  a  saline  solution  for  subcutaneous 
injection  in  a  strength  of  15  grains  to  the  pint.  Nuclein,^  said  to 
represent  the  active  principle  of  yeast,  has  been  recommended  for 
its  effect  in  producing  leucocytosis,  and  may  be  administered  in 
doses  of  15  grains  several  times  daily. 

At  the  present  time  the  action  of  these  remedies  is  as  uncertain 
as  is  that  of  anti-streptococcic  serum ;  but  since  it  is  certain  that  an 
active  serum  can  be  obtained,  and  as  it  is  j^robable  that  the  action 
of  such  a  serum  depends  upon  tlie  leucocytosis  it  apparently  sets 
up,  other  remedies,  so  long  as  they  are  harmless,  which  also  tend 
to  produce  leucocytosis,  are  worthy  of  further  employment. 

Refrigeration. — If  the  temperature  rises  to  a  very  high  degree, 
such  as  105°,  and  is  not  brought  down  by  antipyretic  medicines 
such  as  quinine,  benefit  is  sometimes  found  from  direct  application 
of  cold.  Baths  or  wet  packing  have  been  used,  but  the  disturbance 
to  the  patient  which  these  involve  is  a  serious  disadvantage  in 
peritonitis.  The  simplest  mode  of  reducing  temperature  is  the 
application  over  the  head  either  of  Thornton's  ice-water  cap, 
made  of  india-rubber  tubing,  or  of  Leiter's  temperature  regulator, 
made  of  metal  tubing,  through  either  of  which  a  stream  of  ice-cold 
water  is  kept  running  from  a  reservoir  elevated  above  the  bed,  the 
rapidity  of  the  stream  being  regulated  by  a  tap.  This  application 
of  cold  to  the  head  is  generally  found  to  affect  appreciably  the 
temperature  of  the  whole  body.  If  its  effect  proves  insufficient,  the 
body  may  be  sponged  occasionally  with  water  at  a  temperature 
between  70°  and  80°  F.  A  Leiter's  temperature  regulator  may 
also  be  applied  over  the  abdomen  if  desired.  It  is  most  useful  at 
the  outset  of  the  disease,  when  there  is  tenderness  of  the  uterus, 
with  a  rise  of  temperature.  An  ice-bag  may  be  used  in  the  absence 
of  a  coil.  A  thin  garment  should  be  interposed  between  the  coil  or 
ice-bag  and  the  skin. 

Runge,^  of  Dorpat,  urges  the  treatment  of  puerperal  septicaemia 
by  large  quantities  of  wine  and  brandy,  combined  with  the  use  of 
baths,  instead  of  quinine  or  other  antipyretic.  From  one  to  three 
baths  are  given  in  the  day,  and  their  duration  is  from  five  to  ten 

1  Hofbauer,  Arch.  f.  (iyri.,  1903,  Bd.  68,  p.  859. 

2  Volkmann's  Ramralung,  Kljnischer  Vortriige,  No.  287,  1886. 

M.  66 


1042  The  Practice  of   Midwifery. 

minutes.  The  temperature  is  about  85°  F.  at  first,  and  is  lowered 
to  about  80°  by  the  addition  of  cold  water.  Severe  abdominal  pain 
and  tenderness,  and  violent  vomiting,  are  contra-indications  to  the 
baths  ;  and  they  are,  therefore,  not  available  in  the  worst  cases.  A 
tendency  to  somnolence  or  delirium,  high  temperature,  and 
abdominal  distension,  without  extreme  tenderness,  are  the  strongest 
indications  for  them. 

In  America,  Kibble's  fever-cot,  made  of  cotton  netting,  with 
india-rubber  cloth  beneath,  is  used  for  the  same  purpose,  and  has 
the  advantage  of  involving  less  disturbance  than  baths.  Affusion 
of  water  at  85°  or  80°  to  the  trunk  only  is  practised  every  hour 
until  the  temperature  is  reduced. 

Treatment  of  Pelvic  Cellulitis  and  Pelvic  Peritonitis. — In  these  con- 
ditions the  treatment  has  to  be  directed  chiefly  to  the  local  affections 
and  to  the  consequent  pyrexia,  not  to  any  general  septicaemia.  Hot 
fomentations  should  be  kept  constantly  applied  over  the  lower  part 
of  the  abdomen,  so  long  as  there  is  pain  and  high  temperature. 
Glycerine  of  belladonna  or  tincture  of  opium  may  be  spread  over 
the  skin  beneath.  If  it  is  desired  at  this  stage  to  try  the  effect  of 
an  absorbent,  the  skin  under  the  poultice  may  be  smeared  with 
equal  parts  of  unguentum  hydrargyri  and  unguentum  belladonnae. 
The  bowels  should  be  kept  acting  freely  with  saline  aperients,  if 
constipation  is  present. 

An  essential  part  of  the  treatment  is  complete  and  prolonged 
rest.  A  late  outbreak  of  acute  symptoms  is  often  due  to  the  earlier 
stage  having  been  overlooked,  and  the  patient  getting  up  and 
returning  to  work  prematurely.  The  patient  should  remani  in  bed 
until  the  pain,  tenderness,  and  pyrexia  have  subsided  for  some  con- 
siderable time,  and  the  exudation  is,  in  great  part,  absorbed. 
Caution  about  any  over-exertion  or  exposure  to  cold  is  necessary 
for  weeks  or  months  longer.  If  there  is  persistent  local  pain  long 
after  all  fever  has  subsided,  counter-irritation  to  the  skin  over  the 
painful  spot  may  be  employed.  Liniment  of  iodine  may  be  painted 
over  it  daily  until  the  skin  becomes  sore. 

Irrigation  or  syringing  with  bot  water  at  a  temj)erature  of  from 
110°  to  115°  F.  appears  to  tend  to  reduce  the  inflammation  and 
hasten  the  absorption  of  the  exudation  by  stimulating  the  lympha- 
tics. This  may  be  commenced  as  soon  as  it  can  be  carried  out 
without  too  much  disturbing  the  ]3atient,  and  employed  two  or 
three  times  a  day  until  the  exudation  has  been  in  considerable  part 
absorbed  and  the  patient  is  able  to  get  up.  Absorbent  drugs  are 
not  of  so  much  avail  as  promoting  the  general  nutrition  and  vigour 
of  the  patient  by  good  food  and  tonics.     But  in  the  later  stage, 


Puerperal   Fevers.  1043 

after  the  subsidence  of  fever,  the  liquor  hydrargyri  perchloridi  may 
be  given  in  eighty-minim  doses  three  times  a  day.  This  appears 
to  be  preferable,  in  general,  to  iodide  of  potassium,  as  being  rather 
tonic  than  depressant.  It  may  be  combined  with  quinine,  cinchona, 
or  with  tinct.  ferri  perchloridi.  Iodide  of  potassium,  in  five-grain 
doses,  may  also  be  combined  with  it. 

O'perative  Measures. — As  soon  as  an  abscess  forms  it  must  be 
opened  either  externally  or  internally  through  the  vagina.  If  a 
fluctuating  swelling  can  be  felt  from  the  vagina,  it  should  be  opened 
through  the  posterior  vaginal  fornix.  Care  must  be  taken  to  avoid 
any  injury  to  the  ureters  or  to  the  uterine  arteries,  and  this  is  best 
ensured  by  keeping  strictly  to  the  middle  line.  If  the  abscess  is 
pointing  in  Douglas'  pouch,  the  vaginal  wall  may  be  incised,  and 
then  a  pair  of  sinus  forceps  pushed  into  the  collection  of  pus,  after 
Hilton's  method.  If  the  swelling  is  placed  somewhat  laterally,  it 
is  often  possible  with  care  to  strip  up  the  peritoneum  after  incising 
the  vaginal  wall,  and  thus  to  reach  a  collection  of  pus  in  the  base 
of  the  broad  ligament  or  in  the  utero-sacral  ligaments  without 
opening  the  peritoneal  cavity.  A  drainage  tube  should  be  intro- 
duced and  sewn  in  by  a  stitch  passed  through  tlie  cervix  uteri.  It 
is  best  not  to  irrigate  the  cavity.  If  the  constitutional  symptoms 
indicate  suppuration,  and  a  boggy  feeling  only  can  be  detected  in 
the  swelling,  but  no  distinct  fluctuation,  the  aspirator  may  be  used 
to  search  for  pus. 

When  the  major  part  of  the  swelling  is  situated,  as  it  often  is,  in  the 
iliac  fossa  above  Poupart's  ligament,  an  incision  should  be  made 
similar  to  that  employed  in  the  ligature  of  the  external  iliac 
artery  parallel  to  and  above  the  outer  part  of  Poupart's  ligament, 
or  with  its  centre  over  the  most  prominent  part  of  the  swelling. 
In  most  cases  the  peritoneum  is  stripped  off  the  anterior  abdo- 
minal wall  by  the  abscess,  so  that  there  is  little  risk  of  opening  the 
general  peritoneal  cavity,  but  caution  must  be  employed,  and  the 
layers  of  the  abdominal  wall  carefull}''  incised  so  as  to  make  sure 
of  not  wounding  the  peritoneum.  It  is  usually  possible  to  detach 
the  peritoneum  from  the  iliac  fossa,  and  in  this  way  with  a  suffi- 
ciently free  incision  to  explore  fairly  thoroughly  the  cellular 
tissue  of  one  half  of  the  pelvis,  and  by  making  a  similar  incision 
on  the  other  side  to  evacuate  collections  of  pus  in  either  broad 
ligament. 

It  may  be  desirable  to  make  a  counter-opening  into  the  vagina 
under  the  guidance  of  a  probe  or  finger  passed  into  the  abdominal 
wound,  and  to  pass  a  drainage  tube  right  through,  or  to  close  the 
abdominal  opening  and  to  carry  out  drainage  by  the  vagina  alone. 

66—2 


I044  The  Practice  of   Midwifery. 

In   these   cases   it   is   often    useful   to   employ   a    drainage    tube 
surrounded  by  a  gauze  packing. 

If  an  abscess  has  spontaneously  opened  or  has  been  opened  exter- 
nally, and  the  sinus  does  not  close,  but  pus  continues  to  be  poured 
out  from  a  large  cavity,  a  large  drainage  tube  should  be  introduced 
to  the  full  depth  of  the  cavity.  The  cavity  may  be  washed  out 
daily  by  means  of  a  funnel  with  a  solution  of  iodine  (tr.  iodi  5ij.  ad 
aq.  Oj.),  peroxide  of  hydrogen,  chinosol  1  in  500,  or  sulphurous 
acid  (acid,  sulphurosi  5  j.-ij.  ad  aq.  Oj.).  Such  a  failure  to  close 
is  more  likely  in  the  case  of  an  abscess  due  to  peritonitis  than  in  the 
ordinary  suj)puration  of  pelvic  cellulitis,  especially  when  the  open- 
ing is  high  up  in  the  abdomen,  as,  for  instance,  at  or  near  the 
umbilicus.  Carefully  adjusted  pressure  by  pads  of  wool  may  assist 
in  causing  the  abscess  to  close. 

When  the  collection  of  pus  is  localised  in  tlie  peritoneal  cavity  it 
may  be  feasible  to  open  and  drain  it  without  much  risk,  but  when 
it  is  contained  in  a  suppurating  ovarian  cyst  or  in  the  tubes,  the 
safest  plan  is  to  wait  whenever  possible  until  the  acute  symptoms 
have  passed  away  and  then  to  deal  wath  the  conditions  present  by 
an  abdominal  section.  It  is,  however,  often  desirable  when  the 
patient  is  acutely  ill  and  an  abdominal  section  is  contra-indicated 
to  evacuate  such  collections  of  pus  by  an  incision  through  the 
posterior  vaginal  fornix,  and  to  deal  with  the  diseased  tubes  or  the 
ovarian  cyst  on  a  subsequent  occasion. 

Abdominal  section  has  been  performed  in  some  cases  of  puerperal 
peritonitis  in  view  of  the  good  results  obtained  in  other  cases  of 
general  septic  peritonitis.  After  opening  the  abdomen  the  abdo- 
minal cavity  may  be  washed  out  with  normal  salt  solution  or  merely 
drained,  free  drainage  being  provided  for  by  opening  the  pouch  of 
Douglas,  incising  the  lumbar  fossse  and  passing  drainage  tubes 
through  the  incisions,  and  leaving  the  abdominal  wound  freely  open. 
On  the  whole,  this  method,  especially  when  it  is  combined  with 
continuous  saline  proctoclysis,  gives  better  results  than  any  other. 
The  operation  should  be  carried  out  rapidly  with  as  little  mani- 
pulation as  possible.  It  has  very  rarely,  however,  been  successful 
in  saving  life,  except  in  cases  in  which  it  has  been  performed  very 
shortly  after  the  commencement  of  peritonitis  from  the  sudden 
entrance  of  some  septic  fluid  into  the  peritoneum,  as  from  rupture 
of  a  pyosalpinx.  One  reason  probably  is  that  there  is  generally  too 
extensive  septic  inflammation  in  the  uterus  and  broad  ligaments  to 
allow  of  recovery. 

The  logical  completion  of  the  operation  is  to  remove  the  uterus 
and  thus  get  rid  of  the  main  septic  foci,  and  drain  the  pelvis  very 


Puerperal  Fevers.  1045 

freely.  The  difficulty  about  this  treatment  is  that  if  the  operation 
were  performed  early,  while  the  disease  was  limited  to  septic 
endometritis,  it  would  often  be  performed,  and  the  patient  mutilated, 
unnecessarily.  On  the  other  hand,  when  general  septic  peritonitis 
is  established,  it  has  little  hope  of  success,  and  the  patient  might  be 
too  weak  to  survive  the  operation.  Vaginal  hysterectomy  has  the 
advantage  of  causing  less  shock ;  but  it  may  prove  difficult  from  the 
size  of  the  uterus  if  very  little  involution  has  taken  place,  and  it 
does  not  allow  effectual  flushing  out  of  the  peritoneal  cavity.  If  it 
is  performed  the  broad  ligaments  should  be  secured  by  clamp  rather 
than  by  ligature. 

In  order  to  avoid  the  possibility  of  infection  spreading  from  the 
paralysed  intestines,  many  operators  open  them  at  one  or  two  points 
and  evacuate  the  contents. 

A  less  severe  operation  has  been  recommended  strongly  by  Pryor^ 
among  others,  namely  thoroughly  to  wash  out  the  uterus  and  to 
plug  its  cavity  with  iodoform  gauze.  An  opening  is  then  made  into 
Douglas'  pouch,  through  which  the  finger  is  introduced  to  break 
down  any  adhesions,  and  the  pelvic  cavity  filled  as  far  as  possible 
with  5  per  cent,  iodoform  gauze.  The  plug  in  the  uterus  is  removed 
after  three  days,  and  that  in  the  peritoneal  cavity  is  left  in  for  a 
week. 

In  cases  of  pyaemia  due  to  septic  venous  thrombosis,  ligature 
or  excision  of  the  affected  veins  has  been  carried  out.^  Seitz^ 
has  recorded  38  cases  with  a  mortality  of  6Q  per  cent.  The 
mortality  of  puerperal  pyaemia  is  probably  about  the  same, 
namely  60  to  70  per  cent.,  so  that  the  good  effects  of  the  operation 
are  not  very  apparent.  In  chronic  cases,  however,  some  45  per 
cent,  of  the  patients  recover,  but  it  must  be  remembered  that  the 
mortality  of  chronic  cases  is  not  nearly  so  high  as  that  of  acute 
cases.  The  operation  may  be  carried  out  either  through  an  abdo- 
minal incision  or  by  a  lateral  inguinal  incision.  The  former  is  no 
doubt  the  best.  The  ovarian  and  internal  iliac  veins  should  be  tied 
if  necessary  on  both  sides.  Eemoval  of  theveins is,  however,  usually 
unnecessary.  The  difficulty  is,  the  selection  of  suitable  cases,  and 
the  proper  time  at  which  to  perform  the  operation.  In  no  case 
should  the  operation  be  performed  if  there  are  severe  lung  compli- 
cations or  if  the  heart  is  affected,  and  as  a  general  rule  the  case 

1  W.  R.  Pryor,  The  Treatment  of  Pelvic  Inflammations,  1899. 

'  Bumm,  Berl.  Klin.  Wochenschr.,  1905,  No.  27  ;  Trendelenburg,  Muenchen.  Med. 
Wouhenschr.,  1902,  No.  13  ;  Michels,  Lancet,  1900,  Vol.  I.,  p.  1025  ;  Himpson,  Lancet, 
190:-},  Vol.  L,  p.  1199  ;  Cuff,  Journ.  Obst.  and  (iyn.  Urit.  Einp.,  190G,  Vol.  IX.,  No.  5, 
p.  317. 

"  (Seitz,  Volkniann's  Sammlung,  Klin.  Vortriige,  No.  464. 


1046  The  Practice  of   Midwifery. 

should  be  a  chronic  one,  and,  as  far  as  can  be  made  out,  the  disease 
localised,  a  set  of  conditions  which  are  not  often  met  with  and 
which,  when  they  are,  usually  result  in  the  recovery  of  the  patient. 
Further  experience  is  required  Ijefore  the  ultimate  position  of  this 
operation  in  obstetric  practice  can  be  determined  with  certainty.^ 

Although  as  has  already  been  pointed  out,  the  logical  sequence  of 
opening  the  abdomen  in  cases  of  general  peritonitis  is  the  removal 
of  the  uterus,  yet  it  is  rarely  possible  to  perform  the  operation,  since 
the  patient  is  seldom  in  a  condition  to  stand  it. 

In  a  series  of  116  cases  of  hysterectomy  for  puerperal  sepsis 
collected  by  Jewett,^  the  mortality  was  48  per  cent.,  but  in  the  great 
majority  of  these  there  was  no  peritonitis ;  and  therefore  it  is  very 
doubtful  if  the  mortality  would  have  been  greater  or  so  great  with- 
out hysterectomy.  In  12  cases  where  there  was  partial  peritonitis, 
the  mortality  was  83*3  per  cent.  There  was  no  recovery  from  diffuse 
peritonitis. 

It  thus  appears  that  the  field  of  hysterectomy  is  very  limited,  and 
that  it  gives  no  appreciable  hope  of  success  in  the  virulent  peri- 
tonitis which  kills  within  seven  or  at  most  within  ten  days  after 
delivery. 

If  the  uterus  has  been  perforated  or  injured,  or  if  there  is  any 
suspicion  of  an  abscess  in  the  uterine  wall  or  the  presence  of  a 
sloughing  fibromyoma,  the  organ  should  undoubtedly  be  removed,  as 
it  should  be  also  if  the  placenta  is  so  adherent  that  it  cannot  be 
separated,  and  the  patient  presents  signs  of  septic  infection.^ 

In  137  cases  of  hysterectomy  for  septic  infection  following  labour 
or  abortion  the  mortality  was  63  per  cent.  In  80  cases  there  was 
acute  puerperal  septicemia  with  a  mortality  of  75'6  per  cent.  In 
34  cases  there  was  retention  of  a  portion  of  the  ovum,  and  of  these 
19  died  and  15  recovered.'^  Six  were  cases  of  sloughing  fibroid 
complicating  the  j)uerperium,  and  of  these  3  died.  These  results 
compare  unfavourably  with  the  mortality  of  even  the  worst  cases 
of  puerperal  infection  treated  without  operation. 

The  operation  should  be  performed  by  the  abdominal  route  with 
as  free  an  excision  of  the  bloodvessels  as  possible.  After  removal 
of  the  uterus  the  abdominal  wound  should  be  left  open  and  drained, 
the  drainage  tube,  surrounded  by  gauze,  being  passed  through  into 
the  vagina,  or  if  it  be  decided  to  close  the  abdominal  wound  the 
pelvis  should  be  packed  with  iodoform  gauze,  which  should  be  brought 

1  Macan,  Jouru.  Obst.  and  Gyn.  Brit.  Emp.,  Vol.  XI V.,  No.  4,  p.  2i6. 

"^  American  Gynecology,  February,  1903. 

3  Von  HerfE,  Von  Winckel,  Handbnch.  der  Geburtshiilfe,  1906,  Bd.  3,  Th.  2,  p.  950. 

•*  Cristeanu,  Rev.  de  Gyn.  et  de  Chir.  Abdom.,  July  to  August,  1904,  No.  4. 


I 


Puerperal   Fevers.  io47 

down  into  the  vagina,  and  not  removed  until  the  end  of  five  to  seven 
days.  The  gauze  should,  however,  be  loosened  slightly  at  the  end  of 
twenty-four  hours,  as,  if  this  is  done,  drainage  occurs  more  freely. 
In  all  cases  a  large  rubber  drainage  tube  should  be  placed  in  the 
centre  of  the  gauze,  continuous  proctoclysis  carried  out,  and  the 
patient  placed  in  Fowler's  position  after  the  operation. 


PuERPEEAL   Tetanus. 

Puerperal  tetanus  is  extremely  rare  in  this  country.  No  instance 
of  it  occurred  in  46,089  deliveries  in  the  Guy's  Hospital  Lying-in 
Charity,  and  I  have  met  with  it  only  once.  According  to  modern 
doctrine  it  depends  upon  infection  by  the  bacillus  of  tetanus,  and 
thus  is  really  a  special  form  of  septicaemia.  When  it  occurs  in  puer- 
peral women,  it  is  probable  that  the  microbe  has  been  introduced 
into  the  genital  canal.  It  resembles  surgical  tetanus  in  the  fact 
that  an  important  exciting  cause  is  exj)osure  to  cold,  especially  in 
hot  climates  where  the  microbe  of  tetanus  is  comparatively  common. 
Tetanus  may  occur  after  full-term  delivery,  or  after  abortion, 
especially  if  an  adherent  placenta  has  been  separated  from  the 
uterus.  Of  the  108  cases  collected  by  Vinay  47  followed  an  abortion 
and  61  a  full-term  confinement. 

The  symptoms,  prognosis,  and  treatment  are  similar  to  those  of 
tetanus  in  general.  Sir  James  Simpson  collected  the  records  of 
27  cases,  of  which  22  were  fatal.  Of  Vinay's  108  cases  95  died,  or 
a  mortality  of  88'8  per  cent.  Of  late  hysterectomy  has  been  per- 
formed with  the  hope  of  removing  the  focus  of  the  disease,  but  not 
hitherto  with  success.^ 

The  result  of  the  use  of  tetanus  antitoxin  in  the  human  subject 
has  been  very  disaj^pointing. 

The  new-born  infant  is  also  liable  to  tetsnana  (trismus  neonatoi'um), 
especially  in  hot  countries,  the  seat  of  absorption  being  the 
umbilicus,  on  the  falling  off  of  the  funis  (see  Chapter  XLIL). 

1  Vinay,  Traite  des  Maladies  de  la  Grossesse,  Paris,  1894  ;  Rubeska,  Arch.  f.  Gyn. 
1897,  Vol.  LIV.,  p.  1. 


Chapter  XL. 

PHLEGMASIA   DOLENS,   THROMBOSIS,  EMBOLISM, 
SUDDEN  DEATH,  CHORION  EPITHELIOMA. 

Phlegmasia  Dolens,  or  Peripheral  Venous  Thrombosis. 

The  term  phlegmasia  dolens,  phlegmasia  alba  dolens,  or 
septic  thrombo-phlebitis,  is  applied  to  a  swelling  of  one  or  both 
legs,  characterised  by  pain,  tension  of  the  skin,  brawny  hardness, 
absence  of  pitting  on  pressm-e,  and  a  shining  whiteness  of  the 
surface.  Much  controversy  has  taken  place  as  to  its  true  patho- 
logy. In  former  days  it  was  fancifully  ascribed  to  a  metastasis  of 
the  milk.  From  this  theory,  and  from  the  white  appearance  of  the 
skin,  was  derived  the  popular  term  of  "milk-leg."  By  different 
authorities  it  has  been  regarded  as  inflammation  or  obstruction  of 
the  lymphatics,  as  general  inflammation  of  all  the  tissues  of  the 
limb,  or  as  phlebitis. 

It  is  now  recognised  that  the  most  constant  anatomical  condition 
is  thrombosis  of  the  veins  ;  and  that  phlebitis,  if  it  occurs,  is 
generally  secondar}'',  either  to  the  thrombosis  or  to  inflammation 
of  surrounding  cellular  tissue.  There  must,  however,  be  some- 
thing more  than  obstruction  of  the  veins  to  account  for  the  brawny 
tension  of  the  affected  limb,  the  tissues  of  which  are  filled  with 
coagulable  lymph,  not  with  ordinary  serum.  The  condition  is 
totally  different  from  the  common  oedema  which  is  produced  by 
pressure  on  veins,  or  even  by  thrombosis  of  a  vein  under  different 
circumstances.  This  can  only  be  accounted  for  in  one  of  two 
ways :  either  that  obstruction  of  the  lymphatics  as  well  as  of  the 
veins  is  an  essential  part  of  the  disease,  or  that  there  is  some 
toxemic  condition  of  the  blood,  in  consequence  of  which  the  fluid 
poured  out  is  irritating  to  the  tissues  and  sets  up  a  kind  of  quasi- 
inflammation,  leading  to  the  production  of  coagulable  lymph. 
Probably  both  these  conditions,  and  especially  lymphatic  obstruc- 
tion, actually  play  a  part  in  the  causation.  The  lymphatic 
obstruction  cannot,  however,  be  so  readily  demonstrated  anato- 
mically as  the  venous  thrombosis. 


Thrombosis,    Embolism,    Sudden    Death.      1049 

Causation. — There  is  strong  reason  for  believing  that  the 
presence  of  some  toxin  in  the  blood  generally  has  an  influence  in 
the  production  of  the  coagulation.  This  is  shown  by  the  fact  that 
phlegmasia  dolens  does  sometimes  occur  apart  from  pregnancy  or 
the  puerperal  state,  and  that  this  hapj)ens  in  cases  where  there  is 
some  source  for  septic  absorption.  It  has  been  especially  observed 
when  there  is  ulcerated  cancer  of  some  internal  part,  such  as  the 
cervix  uteri,  but  has  sometimes  occurred  in  a  late  stage  of  phthisis. 
Pathogenic  streptococci  have  been  demonstrated  in  the  thrombus  in 
the  veins,  and  without  doubt  the  majority  of  cases  are  septic  in 
origin.  The  organism  concerned  is  in  most  cases  of  but  feeble 
virulence,  since  the  thrombus  rarely  breaks  down.  In  a  few  cases, 
however,  the  condition  is  followed  or  accompanied  by  general 
vascular  pysemia. 

Phlegmasia  dolens  might  have  been  included  in  the  chapter  on 
puerperal  fevers.  It  has  been  thought  more  convenient  to  describe 
it  separately,  because  it  generally  arises  at  a  later  stage  than  the 
forms  of  fever  there  described,  and  is  only  rarely  associated  with 
general  septic  infection.  It  resembles  parametritis  in  the  fact  that, 
although  it  probably  should  be  included  within  the  definition  of 
septic  diseases,  it  has  a  generally  favourable  prognosis. 

The  impoverished  blood  of  the  pregnant  woman  is  already  prone 
to  clot,  as  is  shown  by  the  tendency  to  thrombosis  in  varicose  veins 
even  during  pregnancy.  This  tendency  is  further  increased  if  there 
has  been  any  undue  hemorrhage  after  delivery.  The  local  con- 
ditions also  favour  thrombosis.  The  veins  have  been  distended  in 
consequence  of  the  abdominal  pressure  in  pregnancy,  and  the 
current  in  them  is  slow  while  the  woman  is  lying  quiet  in  the  puer- 
peral period.  Moreover,  there  are  always  thrombi  in  the  mouths 
of  the  uterine  veins.  From  these  thrombosis  may  easily  extend 
deeper  into  the  uterus,  and  thence  into  the  veins  of  the  broad 
ligaments.  If  it  proceeds  no  further  than  this  it  gives  no  sign  of 
its  existence.  But  from  the  broad  ligament  thrombosis  may  reach 
the  iliac  veins,  and  spread  downward  to  the  femoral  veins.  It  has 
long  been  observed  that  women  who  have  suffered  from  haemor- 
rhage are  most  prone  to  phlegmasia  dolens.  Any  febrile  condition 
also  increases  the  fibrin  in  the  blood,  and  thereby  the  tendency  to 
thrombosis. 

It  is  quite  possible  that  there  are  two  varieties  of  the  disease,  one 
septic  in  origin  and  due  to  the  presence  of  micro-organisms  or  the 
products  of  their  growth,  and  the  second  of  a  non-septic  character 
and  occasioned  by  the  increased  coagulability  of  the  blood  existing 
in  some  pregnant  women. 


1050  The  Practice  of   Midwifery. 

Symptoms  and  Course. — The  commencement  of  symptoms  is 
rarely  within  the  first  week  after  delivery  ;  more  frequently  it  is  in 
the  second  week,  and  still  more  frequently  in  the  third.  Some- 
times, but  not  always,  there  are  preliminary  symptoms  of  malaise 
with  coated  tongue  and  slight  pyrexia.  The  first  characteristic 
symptom  is  that  of  acute  pain  in  the  leg.  The  locality  of  this 
depends  upon  the  course  of  the  local  affection.  More  frequently 
this  commences  in  the  thigh,  near  the  femoral  vessels,  and  spreads 
downward.  Less  frequently,  it  begins  in  the  calf  of  the  leg,  or  near 
the  ankle,  and  extends  upward  and  downward.  Exceptionally  the 
swelling  remains  limited  to  the  upper  part  of  the  thigh. 

The  left  leg  is  affected  more  frequently  than  the  right,  probably 
because  the  venous  circulation  of  the  left  leg  is  more  apt  to  be 
impeded  from  the  presence  of  the  rectum  and  sigmoid  flexure  on 
the  left  side.  Not  uncommonly  the  other  leg  is  affected  afterwards, 
generally  after  an  interval  of  about  a  week.  Exceptionally  the 
attack  is  preceded  by  pelvic  cellulitis  on  the  affected  side.  In  this 
case,  the  thrombosis  is  probably  secondary  to  inflammation  of  the 
cellular  tissue  surrounding  the  iliac  or  femoral  veins. 

The  onset  of  pain  is  accompanied  by  a  rise  of  pulse  and  tempera- 
ture, the  temperature  generally  reaching  101°  or  102°.  Sometimes 
there  are  also  initial  rigors,  and  attacks  of  pain  in  the  chest  may 
occur  due  to  the  presence  of  minute  emboli  with  infarction  and  the 
production  of  small  areas  of  pleurisy.  Swelling  follows  quickly 
upon  tlie  pain.  At  first  the  swelling  may  pit  on  pressure,  as  it 
does  also  when  subsiding.  It  gradually  increases  for  two  or  three 
days,  and  when  it  has  reached  its  height,  has  the  characters  already 
described.  The  white  tense  surface  may  be  variegated  by  knots  of 
purple  superficial  veins.  If  the  skin  is  pricked,  the  fluid  which 
exudes  is  not  thin  serum,  but  coagulable  lymph.  Special  swelling 
and  tenderness  may  be  felt  along  the  course  of  the  affected  veins, 
especially  at  the  onset  or  decline  of  the  affection.  When  the  tension 
is  very  great  they  are  not  so  easy  to  detect.  Motion  of  the  leg  is 
prevented  on  account  of  the  pain  and  pressure  of  the  swelling  on 
the  muscles.  After  from  seven  to  ten  days,  the  pyrexia  generally 
subsides,  and  the  swelling  begins  to  be  less  tense,  and  to  allow 
pitting  on  pressure.  It  does  not  completely  disappear  for  several 
weeks,  usually  as  much  as  five  or  six,  and  often  the  tendency  to 
swelling  remains  for  many  months  afterwards.  Occasionally, 
during  the  early  stage,  there  are  renewed  attacks  of  pyrexia,  with 
extension  of  the  thrombosis  to  fresh  veins. 

In  other  cases  the  disease  runs  a  course  similar  to  that  of  throm- 
bosis  of  the  femoral  or  popliteal  vein,  apart  from  the  puerperal 


Thrombosis,    Embolism,   Sudden   Death.      1051 

state,  and  the  epithet  of  alha  is  not  justified.  The  swelling  remains 
moderate  in  degree,  pits  on  pressure  throughout,  and  never  becomes 
tense  and  hard.     Pain  and  pyrexia  are  comparatively  slight. 

Nowadays  these  cases  appear  to  be  much  commoner  than  the 
classical  phlegmasia  alba  dolens,  probably  from  the  diminished 
frequency  of  puerperal  septicaemia.  They  imply,  at  any  rate,  a 
less  degree  of  septic  element  ;  and  probably  there  are  not  necessarily 
any  microbes  present  in  the  vein  at  all.  Nor  is  there  any  sign  of 
lymphatic  obstruction. 

In  rare  cases  the  arm  becomes  affected  by  phlegmasia  dolens  in 
the  same  way  as  the  leg.  Phlegmasia  dolens  of  the  arm  alone  has 
chiefly  been  observed  apart  from  the  puerperal  state.  But  in  some 
puerperal  patients  the  arms  become  affected  as  well  as  the  legs, 
and  thrombosis  may  occur  in  other  situations  also,  as  in  the  neck. 
These  multiple  thromboses  are  in  most  cases  the  sequelse  of  some 
general  septic  infection,  and  are  of  a  grave  character. 

Pathological  Anatomy. — The  veins  most  frequently  affected 
by  thrombosis  are  the  femoral,  iliac,  popliteal,  tibial,  and  peroneal. 
More  rarely  there  is  thrombosis  in  the  saphenous  veins.  In  the 
later  stage,  the  veins  may  be  inflamed  and  adherent  to  the 
surrounding  cellular  tissue,  especially  when  the  commencement 
of  the  affection  has  been  by  extension  from  pelvic  cellulitis.  The 
lymphatic  glands  are  usually  enlarged,  the  lymphatics  matted 
together  with  the  vessels  by  inflammatory  exudation.  The  clot 
may  be  found  softened  down  by  fatty  degeneration.  When  the 
affection  is  part  of  general  septicaemia,  the  clot  is  more  disintegrated, 
and  there  may  be  pus  in  the  veins. 

Sequelae. — As  a  general  rule,  the  clot  shrinks  up  or  becomes 
disintegrated,  and  the  circulation  through  the  affected  vessels  is 
restored.  More  rarely  the  vessels  become  permanently  obliterated. 
In  these  cases,  more  or  less  swelling,  or  tendency  to  swell,  may 
remain  in  the  leg  for  months  and  even  years,  and  the  use  of  the 
limb  is  impaired  for  a  corresponding  time.  In  either  case  a  vari- 
cose condition  of  the  veins  which  have  been  distended  in  consequence 
of  the  obstruction  is  apt  to  remain. 

liarely  suppuration  takes  place  about  the  affected  vessels.  This 
usually  ends  favourably  after  the  opening  of  the  abscess.  When, 
however,  the  septic  character  predominates  in  the  affection,  and 
especially  in  lying-in  hospitals,  extensive  burrowing  abscesses  may 
be  formed,  with  sloughing  of  muscles  and  cellular  tissue.  Under 
similar  conditions,  the  thrombi  may  become  disintegrated,  and  form 


1052  The  Practice  of   Midwifery. 

septic  emboli  which  set  up  general  pyaemia.  Even  a  healthy  clot 
may  be  detached  and  cause  embolism  of  the  pulmonary  artery. 
The  consequence  may  be  sudden  death,  or  serious  embarrassment 
to  respiration.  Fortunately,  the  detachment  of  a  clot  is  rare,  except 
as  the  result  of  premature  exertion  or  injudicious  manipulation  of 
the  affected  veins. 

Treatment,— The  j&rst  essential  in  treatment  is  absolute  rest, 
and  this  must  be  prolonged  for  a  considerable  time,  with  a  special 
view  to  the  danger  of  embolism  of  the  pulmonary  artery.  For  the 
same  reason  all  friction  should  be  avoided,  and  manipulation  of  the 
affected  vessels  should  be  used  only  with  great  caution.  The 
affected  leg  should  be  somewhat  elevated,  and  guarded  from  pressure 
by  a  cradle.  For  relief  of  pain  it  may  be  wrapped  in  hot  fomenta- 
tions, or  in  flannel  moistened  with  an  anodyne  lotion,  and  covered 
with  oiled  silk.  Opium  or  morphia  should  be  given  until  the  pain 
is  relieved.  Quinine  in  moderate  or  considerable  doses,  according  to 
the  degree  of  pyrexia,  is  of  most  value  in  the  acute  stage.  Later, 
the  tincture  of  perchloride  of  iron  may  be  given.  In  the  later  stage, 
when  the  swelling  is  subsiding,  the  leg  may  be  bandaged  evenly 
with  a  flannel  bandage,  and  still  kept  elevated.  Still  later,  after 
six  or  eight  weeks,  when  there  is  no  longer  fear  of  detachment  of 
clot,  massage  is  useful.  The  patient  should  on  no  account  be 
allowed  to  leave  her  bed  till  all  tenderness  and  swelling  of  the  vein 
have  disappeared.  In  the  septic  forms  of  the  disease  the  treatment 
will  be  merged  into  that  of  puerperal  septicaemia. 

Embolism  and  Theombosis  of  the  Pulmonary  Aeteries. 

Attention  has  long  been  attracted  by  the  startling  cases  in  which, 
quite  unexpectedly,  sudden  death  occurs  either  during  labour  or, 
more  frequently,  after  delivery.  It  is  now  recognised  that  the 
most  frequent  cause  of  sudden  death  is  embolism  of  the  pulmonary 
arteries.  This  embolism  is,  in  the  majority  of  cases,  the  sequel  of 
thrombosis  in  the  veins  of  the  uterus  or  its  vicinity,  or  in  the  iliac 
or  femoral  veins.  It  may  occur  at  any  time  ujj  to  four  or  five 
weeks  after  delivery,  but  is  more  common  after  a  certain  interval, 
when  changes  may  have  taken  place  in  the  clot  which  promote  its 
detachment.  Embolism  may  occur,  however,  even  before  delivery, 
and  when  this  is  the  case,  the  clot  is  most  likely  to  be  derived  from 
a  thrombus  in  a  uterine  sinus  at  the  placental  site.  In  this  situa- 
tion, ante-jMTtiim  thrombosis  may  occur  if  there  has  been  separation 
of  the  placenta,  and  the  thrombus  is  likely  to  be  more  bulky  than 


Thrombosis,   Embolism,   Sudden   Death.      1053 

that  which  would  have  been  formed  after  delivery  and  retraction 
of  the  uterus.  Then,  when  retraction  does  occur  in  the  course  of 
labour  or  after  delivery,  the  loose  thrombus  may  be  squeezed  out 
and  carried  to  the  pulmonary  arteries.  According  to  Spiegelberg,^ 
this  accident  most  often  occurs  when  premature  labour  is  induced  by 
some  method  which  involves  the  risk  of  separating  the  placenta. 

The  predisposing  causes  are  therefore  all  those  which  tend  to 
coagulation  of  the  blood,  especially  hsemorrhage,  depression  of  the 
circulation  from  hsemorrhage  or  exhaustion,  pyrexia  due  to  any 
cause,  and  the  entrance  of  septic  material  into  the  circulation.  It 
is  only  the  milder  forms  of  septic  infection,  however,  which  are 
likely  to  lead  to  sudden  death  through  embolism  of  the  main  trunk 
or  largest  branches  of  the  pulmonary  artery.  If  the  clot  itself  has 
a  definitely  septic  character,  and  contains  septic  organisms,  it 
quickly  becomes  disintegrated.  Small  fragments  are  then  apt  to 
be  detached,  and  either  plug  small  branches  of  the  pulmonary 
artery,  or  pass  through  the  pulmonary  capillaries  and  cause 
minute  emboli  in  other  parts  of  the  body.  This  condition  has 
already  been  described  in  the  chapter  on  puerperal  fevers  as  leading 
to  visceral  pyaemia.  The  clot  may,  however,  be  apparently 
healthy,  even  though  entrance  of  septic  material  has  had  some- 
thing to  do  with  the  coagulation :  perhaps  because  the  influence 
has  been  that  of  sapraemia  only,  not  septicaemia.  In  such  case,  if 
detached  at  all,  it  is  more  likely  to  be  detached  in  a  considerable 
mass,  and  plug  a  large  branch  or  the  main  stem  of  the  pulmonary 
artery. 

Considerable  controversy  has  taken  place  as  to  whether  individual 
cases  should  be  interpreted  as  embolism  or  as  primary  thrombosis 
of  the  pulmonary  artery.  On  the  one  hand,  it  is  argued,  and  the 
argument  has  much  weight,  that  it  is  not  likely  that  coagulation 
would  take  place  first  in  a  situation  where  the  current  is  so  rapid 
as  it  is  in  the  pulmonary  arteries.  On  the  other  hand,  it  is  said 
that  the  pulmonary  artery  breaks  up  at  once  into  a  number  of 
branches,  which  radiate  from  it  at  different  angles  to  the  several 
parts  of  the  lung.  Consequently  a  large  extent  of  surface  is  pre- 
sented to  the  blood,  and  there  are  numerous  angular  projections 
into  the  currents,  both  which  conditions  are  calculated  to  induce 
the  spontaneous  coagulation  of  the  fibrin.^  This  mode  of  bifurca- 
tion must  also  cause  considerable  retardation  of  the  current,  which 
may  therefore  become  slow  enough  to  allow  coagulation  when  the 
heart's  action  is  greatly  depressed. 

'  Lehrbuch  der  Geburtshlilfe,  English  translation,  2nd  ed.,  Vol.  II.,  p.  354. 

'  Humphry,  On  the  Coagulation  of  the  Blood  in  the  Venous  Systeni  during  Life. 


I054  The  Practice  of   Midwifery. 

Extensive  coagulation  may  be  found  in  the  pulmonary  arteries 
and  right  heart  after  death,  having  the  appearance  of  being  due 
to  thrombosis.  It  is  to  be  remembered,  however,  that  an  embolus 
always  causes  the  deposit  of  fresh  fibrin  on  its  surface,  and  thus 
leads  to  secondary  thrombosis,  extending  backward  toward  the 
heart.  A  small  primary  embolus  may  thus  escape  detection. 
Moreover,  it  is  often  difficult  to  say  whether  the  extensive 
thrombosis  may  not  have  been  formed  only  during  the  death 
agony. 

Most  of  the  best  pathologists  are  of  opinion  that  embolism  of  the 
pulmonary  arteries  is  much  more  frequent  than  primary  thrombosis. 
An  embolus  is  distinguished  by  its  being  more  decolorised,  and 
distinct  in  appearance  from  the  thrombosis  formed  upon  it,  and 
by  its  generally  being  situated  at  a  point  of  bifurcation  of  the 
artery,  at  which  it  has  been  arrested.  Also  it  is  not  moulded  in 
shape  to  the  vessel  which  contains  it,  and  occasionally  it  may  be 
fitted  on  to  the  clot  elsew^here  from  which  it  has  been  detached. 

An  ante  -  mortem  arterial  thrombus  presents  a  rounded  end 
toward  the  heart,  and  is  dense,  consisting  of  layers  of  decolorised 
fibrin.  It  may  be  softened  in  the  centre  from  commencing 
degeneration.  It  is  non-adherent  to  the  walls  of  the  vessel,  and 
may  allow  a  little  space  for  the  blood  to  circulate  between. 

One  fact  about  the  clinical  history  is  in  favour  of  the  view 
that  embolism  is  much  more  frequent  than  primary  thrombosis  of 
the  pulmonary  artery.  This  is  that,  in  the  great  majority  of  cases, 
the  attack  comes  on  with  appalling  suddenness,  which  forms  one 
of  its  most  striking  characteristics.  It  is  thus  allowed  that  there  is 
no  difference  in  symptoms  between  embolism  and  what  is  inter- 
preted as  having  been  primary  thrombosis.  It  might  be  expected, 
however,  that  the  onset  of  symptoms  would  be  more  gradual  in 
thrombosis,  as  it  seems  to  have  been  in  the  case  recorded  above, 
where  thrombosis  commenced  in  the  right  auricle. 

The  cases  which  are  most  likely  to  be  due  to  thrombosis  com- 
mencing either  in  the  auricle  or  in  the  pulmonary  artery  itself  are 
those  in  which  the  symptoms  of  dyspnoea  come  on  within  a  few 
days  after  delivery,  and  in  which  they  have  been  preceded  by  great 
depression  of  the  circulation,  owing  to  exhaustion  from  difficult 
labour,  or  haemorrhage,  or  both. 

Symptoms  and  Course. — The  primary  thrombosis  in  a  pelvic 
vein,  if  such  has  existed,  gives,  as  a  rule,  no  sign  of  its  presence. 
Hence  the  attack  of  dyspnoea,  in  the  majority  of  cases,  comes  on 
quite    unexpectedly.      In    some   cases   the   puerperal   period   has 


Thrombosis,   Embolism,   Sudden   Death.      1055 

apparently  progressed  quite  normally,  and  the  patient  may  be 
beginning  to  get  about  again.  Frequently,  however,  there  has 
either  been  a  protracted  and  exhausting  labour,  or  there  has  been 
more  or  less  pyrexia  within  the  first  week,  indicating  some  degree 
of  septic  disturbance.  In  other  cases,  again,  the  attack  comes  on 
within  the  first  few  days,  esj)ecially  after  hsemorrhage,  or  depression 
of  the  heart  from  exhaustion. 

The  starting-point  appears  frequently  to  be  some  slight  exertion. 
The  patient  is  then  suddenly  seized  with  the  most  intense  dyspnoea. 
She  gasps  and  struggles  for  breath,  and  all  the  auxiliary  muscles 
of  respiration  are  thrown  into  action.  The  face  is  livid  and  purple, 
or  sometimes  pale.  The  heart's  action  at  first  is  violent  and 
tumultuous  ;  soon  it  becomes  feeble  and  irregular.  The  pulse  is 
small  and  also  irregular.  Eespiration  is  hurried,  and  air  may  be 
heard  to  enter  the  lungs  freely. 

If  the  main  trunk  of  the  pulmonary  artery  is  blocked,  death 
follows  after  a  struggle  of  a  few  minutes.  If  only  a  main  branch 
is  plugged,  the  symptoms  after  a  while  may  become  mitigated  in 
some  degree,  but  the  violence  of  dysj)noea  is  apt  to  be  renewed 
on  any  slight  exertion.  Less  frequently,  the  first  onset  is  not  so 
intense,  but  the  attacks  recur  with  increasing  severity.  This 
probably  happens  chiefly  in  cases  in  which  there  is  primary 
thrombosis  in  the  heart  or  in  the  pulmonary  artery  itself.  A  fair 
number  of  cases  has  been  recorded,  although  only  a  small  minority 
of  the  whole,  in  which  the  patient  has  ultimately  recovered  after 
symptoms  pointing  to  pulmonary  embolism  or  thrombosis. 

In  some  of  the  cases  not  very  rapidly  fatal  a  systolic  bruit  has 
been  observed  over  the  pulmonary  artery.  It  is  probable  that  this 
may  occur  in  the  case  of  embolism  at  the  entrance  of  a  main  branch 
of  the  artery,  when  the  secondary  thrombus  extends  towards  the 
heart.  If  a  primary  thrombus  is  tethered  in  the  heart,  and  extends 
through  the  valves  into  the  artery,  the  bruit  may  be  expected  to  be 
more  marked.  In  this  case  the  second  sound  may  also  be  affected, 
the  clot  preventing  the  closure  of  the  valves.  If  the  patient 
eventually  survives,  recovery  is  complete.  The  circulation  is 
restored,  probably  through  disintegration  of  the  clot,  and  any  bruit 
which  may  have  been  heard  disappears. 

Prophylaxis. — The  most  essential  point  in  prophylaxis  is  to 
enjoin  complete  and  prolonged  rest  in  all  cases  in  which  there  is 
evidence  of  venous  thrombosis.  This  should  be  continued  until 
at  least  five  or  six  weeks  have  passed,  and  the  vein  is  no  longer 
tender  and  indurated.      More  prolonged  rest  in  bed  than  usual  is 


1056  The  Practice  of   Midwifery. 

also  desirable  in  all  cases  in  which  there  has  been  great  exhaus- 
tion from  hfemorrhage,  or  considerable  pyrexia  indicating  septic 
disturbance  in  the  first  week  after  delivery. 

Treatment. — In  many  cases  death  is  too  rapid  to  allow  any 
treatment.  In  the  first  instance  the  effort  should  be  to  keep  the 
patient  alive,  and  maintain  the  action  of  the  heart  by  stimulants 
such  as  brandy  and  ether.  Ether  may  be  given  by  subcutaneous 
injections  of  twenty  minims  at  a  time,  if  the  patient  cannot  swallow. 
The  administration  of  oxygen  may  prove  useful.  Ammonia  is  a 
useful  stimulant,  and  has  also  been  recommended  on  the  ground 
that  it  may  tend  chemically  to  promote  the  solution  of  the  clot,  or, 
at  any  rate,  to  prevent  further  thrombosis.  Twenty  minims  of 
liquor  ammonite,  or  five  grains  of  carbonate  of  ammonia,  may  be 
given  every  hour  for  a  while,  and  afterwards  at  longer  intervals. 
If  there  is  cyanosis  of  the  face,  and  other  evidence  of  over-disten- 
sion of  systemic  veins,  a  small  venesection,  or  some  leeches  applied 
to  the  chest,  may  assist  in  the  restoration  of  equilibrium. 

If  the  patient  survives  the  first  attack  of  dyspnoea,  and  obtains 
some  relief,  it  is  of  the  utmost  importance  that  she  should  be  kept 
absolutely  at  rest,  and  not  raised  in  bed,  or  allowed  to  make  any 
muscular  exertion  for  any  purpose.  Liquid  food  should  be  given 
frequently,  and  in  small  quantities.  The  same  precautions  should 
be  maintained  for  a  considerable  time  after  the  severity  of  symptoms 
has  abated,  since  a  renewed  attack  is  liable  to  be  brought  on  by 
any  imprudence. 

Embolism  of  Systemic  Aktbries. 

Embolism  of  systemic  arteries  is  rarer  than  that  of  pulmonary 
arteries.  In  the  majority  of  cases  the  clot  is  derived  from  the 
left  heart.  The  same  conditions  of  blood  as  those  which  predispose 
to  venous  thrombosis  promote  its  formation.  In  some  recorded 
cases  there  has  been  antecedent  rheumatism,  and  vegetations  have 
been  detached  from  the  valves  of  the  heart.  In  others  there  has 
been  puerperal  endocarditis,  generally  of  septic  origin.  In  others 
the  thrombosis  probably  commences  in  the  auricular  appendix, 
or  elsewhere  in  the  auricle,  the  circulation  having  been  much 
depressed  by  exhaustion  or  haemorrhage.  In  some  cases  it 
has  been  inferred  that  there  has  been  primary  thrombosis  in 
the  arteries  themselves,  the  symptoms  having  been  gradual  in 
their  onset,  and  the  arterial  walls  having  been  found  in  a  morbid 
condition- 


Thrombosis,    Embolism,   Sudden  Death.      1057 

Symptoms  and  Course. — The  arteries  most  frequently  affected 
are  the  femoral,  brachial,  and  cerebral.  When  the  artery  of  a  limb 
is  plugged,  there  is  generally  intense  pain  in  the  situation  of  the 
affected  artery,  sudden  in  its  origin,  but  persistent.  Pulsation  in 
the  distal  portion  of  the  artery  ceases,  and  the  limb  becomes  cold, 
powerless,  and  sometimes  oedematous.  There  may  be  excessive 
pulsation  in  the  artery  above  the  plug.  In  some  cases  gangrene 
of  the  limb  has  followed.  Gangrene  is  not  usually  the  result  of 
obstruction  of  the  main  artery  of  a  limb  in  persons  who  are  young 
and  otherwise  healthy,  a  collateral  circulation  being  established. 
Hence,  in  the  puerperal  cases,  a  morbid  condition  of  the  blood,  or 
some  venous  thrombosis  in  addition,  is  probably  an  element  in  the 
causation.  When  gangrene  of  a  limb  occurs  in  the  puerperal  state, 
the  prognosis  is  most  grave,  a  fatal  result  being  very  common. 
Cases,  however,  are  on  record  in  which  the  patient  has  recovered 
after  formation  of  a  line  of  demarcation  and  amputation  of  the 
limb. 

When  embolism  of  an  important  cerebral  artery  occurs,  softening 
of  the  brain  and  paralysis,  generally  taking  the  form  of  hemiplegia, 
are  apt  to  follow.  Embolism  of  the  ophthalmic  artery  leads  to 
complete  blindness  of  the  affected  eye.  This  occurs  in  septicsemic 
cases,  and  is  followed  by  destruction  of  the  eye,  and  usually  by 
a  fatal  result. 

Treatment. — The  limb  should  be  elevated  and  kept  warm  by 
flannel  and  hot-water  bottles.  Opiates  must  be  given  until  pain 
is  relieved.  The  strength  should  be  supported  by  nourishing 
diet.  Any  concomitant  septic  condition,  must  be  treated  in  the 
usual  way. 

Entrance  of  Air  into  the  Veins. 

Next  to  pulmonary  embolism  and  thrombosis,  the  most  notable 
cause  of  sudden  death  during  labour  or  shortly  after  delivery 
appears  to  be  entrance  of  air  into  the  veins.  It  is  well  known  that 
the  entrance  of  air  in  considerable  quantity  into  large  veins  near 
the  heart  is  apt  to  prove  fatal.  This  is  sometimes  seen  in  surgical 
operations  upon  the  neck.  The  condition  of  the  uterine  veins  is 
somewhat  similar  to  that  of  the  veins  at  the  lower  part  of  the  neck. 
They  have  large  mouths,  and  are  closely  united  with  the  tissue  in 
which  they  lie,  so  that  they  cannot  collapse  when  not  closed  by 
contraction  of  the  uterus.  They  are  also  near  enough  to  the  chest 
to  be  affected  by  respiratory  aspiration. 

M.  67 


1058  The  Practice  of   Midwifery. 

The  cause  of  death  in  such  cases  is  probably  complex.  The  right 
heart  filled  with  air,  which  is  compressible  and  has  no  appreciable 
momentum  as  compared  with  blood,  cannot  readily  empty  itself. 
The  air  bubbles  also  do  not  readily  pass  through  the  pulmonary 
capillaries,  and  act  somewhat  as  emboli.  If  the  air  enters  a  vein 
distant  from  the  heart,  or  enters  in  moderate  quantity,  so  that  the 
right  heart  does  not  become  filled  with  air,  these  effects  are  not 
produced. 

For  air  to  enter  the  uterine  veins  three  conditions  are  necessary. 
There  must  be  air  or  gas  in  the  uterus,  the  uterus  must  be  relaxed, 
and  the  mouths  of  the  veins  must  be  open,  or  filled  only  by  a  soft 
easily  displaceable  thrombus.  The  conditions  may  be  fulfilled 
either  before  delivery,  when  the  placenta  is  separated  or  partially 
separated,  or  after  delivery,  especially  when  delivery  is  only  just 
completed.  Air  may  reach  the  vagina  and  thence  the  uterus 
merely  from  the  effect  of  position,  when  the  vagina  is  patulous. 
It  may  also  still  more  easily  gain  access  during  obstetric  operations 
or  manipulations.  Aspiration  into  the  veins  may  occur  from  the 
variations  of  intra-abdominal  pressure,  together  with  relaxations  of 
the  uterus  alternating  with  contractions.  Air  may  also  be  forced 
into  the  veins  by  contraction  of  the  abdominal  muscles,  occurring 
when  the  exit  through  the  vagina  is  impeded. 

The  most  marked  cases  have  occurred  when  water  has  been 
injected  into  the  uterus  before  delivery.  The  placenta  may  then 
be  separated  by  the  pressure  of  the  water,  and  air  already  in  the 
vagina  may  gain  entrance,  or  air  may  be  injected  with  the  w^ater. 
If  a  Higginson's  syringe  is  used,  air  is  almost  certain  to  be  injected. 
The  objections  on  this  ground  to  the  method  of  inducing  labour 
by  injections  of  water  into  the  uterus  have  already  been  explained 
(see  p.  801).  The  same  result  has  sometimes  followed  even  a 
vaginal  douche ;  and  it  has  been  thought  that,  even  if  no  air  has 
been  injected  with  the  water,  the  j)ressure  of  the  water  may  have 
forced  into  the  uterus  some  air  already  in  the  vagina.  Again, 
sudden  death  has  followed  the  washing  out  of  the  uterus  for  the 
removal  of  septic  material  after  delivery. 

In  other  cases  sudden  death  has  occurred  shortly  after  delivery, 
and  the  entrance  of  air  into  the  circulation  has  been  verified  by 
autopsy.  In  some  of  these  instances,  the  accident  has  happened 
when  the  hand  has  been  introduced  into  the  uterus,  as  for  the 
removal  of  an  adherent  placenta  ;  in  others  it  has  been  quite 
spontaneous.  Another  mode  of  origin  for  the  accident  is  the  dis- 
tension of  the  uterus  by  gas  from  decomposition  of  the  foetus. 
On  delivery  of  the  foetus  and  sej)aration  of  the  placenta,  some  of 


Thrombosis,    Embolism,   Sudden   Death.      1059 

the  gas  may  then  be  aspirated  or  forced  mto  the  veins.  It  is  quite 
possible,  however,  that  many  of  these  cases  in  reality  are  due  to  the 
presence  of  a  gas-producing  organism  in  the  tissues,  such  as  the 
bacillus  aerogenes  capsulatus,  which  has  been  found  in  some  of 
the  cases  in  which  air  was  present  in  the  blood. 

On  post-mortem  examination,  the  left  heart  is  found  contracted, 
the  right  heart  distended  and  filled  with  air.  There  is  froth  in 
the  pulmonary  arteries.  The  vena  cava  and  pelvic  and  uterine 
veins  may  contain  air.  It  is,  of  course,  necessary  to  distinguish 
the  case  in  which  gas  has  been  produced  by  post-mortem 
decomposition. 

Symptoms. — The  symptoms  indicate  pulmonary  obstruction, 
and  thus  closely  resemble  those  of  pulmonary  embolism.  There 
is  a  sudden  intense  struggle  for  breath ;  the  face  is  purple  and 
livid,  the  pulse  small  and  irregular.  Sometimes  convulsions 
occur.  Soon  unconsciousness  and  death  follow.  A  churning 
sound  in  the  heart  has  sometimes  been  heard  on  auscultation. 
As  a  rule,  however,  it  will  be  impossible  positively  to  distinguish 
between  entrance  of  air  into  the  circulation  and  pulmonary 
embolism. 

Prophylaxis. — Induction  of  premature  labour  by  injection  of 
water  into  the  uterus  should  be  avoided.  Even  for  the  vaginal 
douche,  an  irrigator  should  be  used,  and  the  tube  should  be  emptied 
of  air.  If  the  Higginson's  syringe  is  ever  used  care  should  be 
taken  that  the  outflow  from  the  vagina  is  free,  and  the  injection 
should  be  gentle  at  first. 

Syncope  and  Shock. 

In  cases  of  serious  valvular  disease  of  the  heart,  fatal  syncope 
is  apt  to  occur  during  or  after  labour,  as  already  described  (see 
p.  552).  Apart  from  any  valvular  disease,  various  cases  of  sudden 
death  in  parturition  or  the  puerperal  state  are  on  record,  in  which 
the  results  of  post-mortem  examination  have  excluded  the  possi- 
bility of  embolism  or  thrombosis  of  the  pulmonary  arteries,  or  the 
entrance  of  air  into  the  circulation.  These  must  be  attributed  to 
failure  of  the  heart.  It  is  a  comparatively  common  experience  that, 
after  post-j^artum  hajmorrhage  not  sufficient  in  amount  to  kill 
under  ordinary  circumstances,  fatal  syncope  may  occur,  sometimes 
from  the  effect  of  some  exertion,  or  of  the  patient's  head  being 
raised  imprudently.      Even    without    any  excessive   hemorrhage, 

67—2 


io6o  The  Practice  of   Midwifery. 

syncope  may  occur,  and  in  some  cases  has  been  fatal,  especially 
when  the  patient  has  been  exhausted  by  severe  labour.  Predis- 
posing causes  may  be  the  so-called  fatty  degeneration  of  the 
muscular  fibres  of  the  heart,  or  mere  thinness  of  its  muscular  wall, 
which  is  generally  associated  with  deposit  of  adipose  tissue  outside. 
Dilatation  of  the  heart  from  any  cause,  such  as  Bright's  disease,  or 
disease  of  the  lungs,  may  also  predisj)ose  to  syncope.  Death  from 
syncope  has  occurred  in  pregnancy,  as  well  as  during  or  after 
labour,  but  much  more  rarely. 

Sometimes  the  approach  of  death  is  more  gradual,  and  is  pre- 
ceded by  symptoms  resembling  those  of  shock.  The  face  is  anxious 
and  pinched,  the  skin  pale,  the  lips  livid,  the  extremities  cold,  the 
pulse  rapid  and  almost  imj)erceptible,  the  skin  generally  moist 
with  sweat.  There  is  an  absence  of  the  violent  struggle  for  breath 
and  tumultuous  action  of  the  heart  which  denote  pulmonary 
obstruction.  Sometimes,  as  when  death  is  impending  from  the 
effect  of  severe  haemorrhage,  there  is  restlessness  associated  with 
considerable  strength  of  voice  and  muscular  strength  generally,  but 
with  very  rapid,  feeble  pulse.  These  symptoms  chiefly  occur  after 
severe  labour  in  women  of  highly  susce^Dtible  neurotic  temperament, 
and  the  shame  of  parturition  in  an  unmarried  woman  sometimes 
adds  to  the  eftect.  Some  excess  of  haemorrhage  may  also  be  con- 
cerned in  their  production.  The  sudden  lowering  of  abdominal 
tension  is  probably  an  element  in  the  causation.  Combined  with 
a  paralysis  of  the  sympathetic  nerves,  due  to  the  impression  upon 
the  nervous  system,  it  allows  a  great  proportion  of  the  blood  to 
collect  in  the  large  veins  within  the  abdomen,  while  but  little  passes 
through  the  heart. 

Treatment  of  Shock.- — The  treatment  is  to  apply  warmth  to 
the  extremities,  and  give  stimulants,  such  as  brandy,  ether,  and 
ammonia,  as  well  as  liquid  nourishment,  as  strong  beef-tea  or 
essence  of  meat.  Ether  may  be  administered  subcutaneously.  If 
failure  of  the  heart  is  threatened,  the  inhalation  of  nitrite  of  amyl 
is  likely  to  be  of  use,  as  it  is  in  threatened  syncope  during  the 
administration  of  chloroform  ;  for  it  acts,  not  only  by  relaxing 
the  arteries,  but  by  stimulating  the  heart,  as  may  be  proved  by 
sj)hygmographic  tracings,  and  thus  it  relieves  the  circulation  in  a 
double  way. 

Othee  Causes  of  Suddisn  Death. 

Sudden  deaths  from  rupture  of  an  aneurism  in  labour,  acute 
cedema  of  the  lungs,  rupture  of  the  heart,  rupture  of  the  spleen  or 


Thrombosis,   Embolism,   Sudden   Death.     1061 

of  one  of  the  splenic  arteries,  have  been  recorded,  but  are  very 
rare.  In  women  prone  to  cerebral  hsemorrhage  the  exertion  of 
labour  may  precipitate  the  rupture  of  an  artery.  There  may  then 
be  convulsions  at  the  outset,  followed  by  coma  and  paralysis, 
generally  hemiplegia.  Death  in  this  case  may  be  rapid,  but  is 
not  absolutely  sudden,  as  when  due  to  failure  or  obstruction  of  the 
circulation. 

Some  causes  of  sudden  death  would  not  be  suspected  unless 
revealed  by  post-mortem  examination.  Thus,  a  woman  in  the 
Guy's  Hospital  Lying-in  Charity,  somewhat  advanced  in  apparently 


Fig-.  495. — Chorionepithelioma  of  uterus  with  lutein  cysts  in  both  ovaries. 

normal  labour,  became  suddenly  collapsed,  and  died  before  delivery 
could  be  completed  with  forceps.  At  the  autopsy,  it  was  found 
that  the  omentum  was  adherent  to  the  uterus.  Some  separation 
had  occurred,  probably  from  the  retraction  of  the  uterus  with  the 
advance  of  labour,  and  fatal  hsemorrhage  had  taken  place  into  the 
peritoneal  cavity. 


Choeionepithelioma,  or  Deciduoma  Malignum. 

A  peculiar  form  of  malignant  disease  following  pregnancy  was 
first  described  by  Sanger  in  1888  under  the  title  of  deciduoma 
malignum.       Chiari     had    previously    described    three    cases    of 


io62  The  Practice  of   Midwifery. 

carcinoma  of  the  fundus  uteri  following  the  puerperium,  of  which 
two  occurred  in  young  women  aged  22  and  23.  At  the  present 
time  a  large  number  of  cases  have  been  described,  some  being  long- 
preserved  specimens,  but  the  disease  is  still  to  be  regarded  as  a  rare 
one.  The  chief  clinical  features  of  the  disease  are  that  it  both 
spreads  locally  and  forms  metastatic  deposits  with  extreme  rapidity, 
so  that,  in  the  greater  number  of  cases,  it  has  proved  fatal  within 
from  ten  weeks  to  six  months  after  the  puerperium.  It  may  occur 
at  any  age  from  17  to  55  ;  but  a  large  proportion  of  cases  has  been 
in  young  women.  Thus,  about  64  per  cent,  of  the  patients  have 
been  under  the  age  of  35  ;  and  there  are  more  cases  between  the 
ages  of  25  and  30  than  in  any  other  quinquennium.  The  average 
age  of  the  patients  in  recorded  cases  is  31  years. 

Causation. — The  disease  may  occur  after  labour  at  full  term  or 
premature,  after  abortion,  or  after  a  vesicular  mole.  Premature 
deliveries  and  abortions  are  antecedents  in  greater  than  the  relative 
proportion,  25  to  35  per  cent.,  as  compared  with  full-term  deliveries, 
20  to  25  per  cent.  But  the  most  remarkable  circumstance  in  the 
causation  is  the  relation  to  vesicular  mole,  which  was  the  antecedent 
in  49  cases  out  of  the  first  90.  The  disease  is  almost  entirely,  if  not 
entirely,  confined  to  multiparse.  In  some  cases  metastases  have 
occurred  while  a  vesicular  mole  has  been  still  in  the  uterus.  In 
others  vaginal  metastases  have  been  found  having  the  structure  of 
chorionepithelioma  after  a  pregnancy  or  vesicular  mole  without 
any  disease  in  the  uterus. 

It  is  now  generally  accepted  that  the  disease  is  associated  with 
an  antecedent  pregnancy  in  practically  every  case,  and  the  statistics 
of  its  relation  to  vesicular  mole  prove  its  connection  with  pregnancy. 
A  vesicular  mole  occurs  only  once  in  about  2,000  pregnancies. 
Not  more,  therefore,  than  about  one  woman  in  40,000  has  had  a 
vesicular  mole  within  a  year.  On  this  assumption,  the  probability 
against  a  vesicular  mole  being  antecedent  in  as  many  as  49  out  of 
the  90  cases,  if  there  is  no  causal  relation  between  them,  can  be 
calculated  by  the  mathematical  doctrine  of  probabilities.  It  is 
so  enormous  that  it  amounts  to  a  certainty  that  the  causal 
relation  does  exist.  If  this  is  true  as  regards  vesicular  mole, 
there  is  a  strong  presumption  that  it  extends  to  other  forms  of 
pregnancy. 

It  is  now  almost  universally  agreed  that  the  disease  arises  from 
the  foetal  trophoblast,  and  that  chorionepithelioma  is  therefore  the 
most  suitable  title  for  it.  It  is  admitted,  however,  that  a  similar 
structure  is  found  apart  from  pregnancy  and  in  either  sex  in  certain 


Thrombosis,    Embolism,   Sudden   Death.      1063 

tumours,  described  as  embryomata  or  teratomata.^  These  originate 
generally  in  the  testis  or  ovum,  but  have  occasionally  been  found 
elsewhere,  as  in  the  mediastinum.  There  appears  to  be  a  formation 
in  them  of  three  layers  like  those  of  the  early  ovum,  and  of  certain 
structures  derived  from  these.  Thus,  not  only  are  growths  found 
having  the  structure  of  chorionepithelioma,  but  secondary  growths 
have  been  found  in  the  vessels  resembling  vesicular  mole.  It  may 
be   suggested   that    they    are   attempts    at   development    without 


Fig.  496. — Microscopic  section  of  chorionepithelioma  showing  masses  of 
syncytium  and  discrete  cells  of  Langhan's  layer. 

impregnation  of  the  germ  plasm,  which  normally  should  be  limited 
to  the  testicle  and  ovary,  but  may  occasionally  be  included  in  some 
other  part  of  the  body. 

A  very  few  cases  have  been  recorded  as  much  as  two  years  after 
the  menopause,  or  from  two  to  four  years  after  the  pregnancy  to 
which  the  disease  was  attributed.      There  is  ground,  therefore,  for 

1  Chorionepithelioma  in  the  male  is  intensely  malignant.  iSo  far  definite  foetal 
villi  do  not  appear  to  have  been  met  with  in  man,  but  otherwise  the  tumours  are  iden- 
tical in  structure.  No  doubt  in  this  sex  they  take  origin  from  ectodermal  elements, 
and  it  has  been  proposed  to  call  them  ectodermal  malignant  syncytioma. 


1064 


The  Practice  of   Midwifery. 


believing  that,  in  very  exceptional  cases,  it  may  remain  latent  for 
a  considerable  period.  As  a  rule,  the  symptoms  appear  within  a 
few  months  after  the  pregnancy,  and  frequently  follow  uj)on  it 
almost  immediately.  Two  cases  also  have  been  recorded,  one  in  a 
young  girl  of  8|  years  of  age  and  the  second  in  a  woman  of  75 
years  of  age,  in  whom  apparently  all  possibility  of  pregnancy  could 
be  excluded.  In  such  cases  as  these  there  is  at  present  no  adequate 
explanation  of  the  occurrence  of  these  tumours.^ 


—  cl 


Fig.  497. — A  collection  of  epithelial  cells  lying  within  a  blood-vessel  in  the 
muscular  wall  of  the  uterus,  from  a  case  of  hydatidiform  mole  (see 
Fig.  286). 


Pathology — The  most  characteristic  feature  of  the  growth  is 
the  presence  of  syncytium.  This  consists  of  masses  of  protoplasm 
containing  large  nuclei,  but  not  divided  into  cells.  It  occurs 
sometimes  in  the  form  of  masses  or  bands  (Fig.  496),  but 
frequently  forms  a  reticulum,  surrounding  spaces  which  may 
contain  blood,  like  the  spaces  in  the  trophoblast  of  an  early  ovum 
(see  p.  72).  The  protoplasm  of  the  syncytium  stains  more  deeply 
than  that  of  the  cells.  With  the  syncytium  are  associated  masses 
of  large  cells  with  large  nuclei.  As  the  syncytium  resembles  the 
syncytium  of  an  early  ovum,  so  these  cells  exactly  resemble  the 

1  Eden,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  1907,  Vol.  XII.,  No.  6,  p.  424. 


Thrombosis,    Embolism,   Sudden   Death.      1065 

cells  of  the  trophoblast,  corresijonding  to  Langhan's  layer  of  the 
chorionic  villi,  or  those  seen  forming  masses  in  vesicular  mole. 

There  are  three  varieties  of  structure  in  the  growths  described 
as  chorionepithelioma. 

(1)  In  comparatively  few  cases,  notably  one  described  by 
Marchand,  one  by  Neumann,  and  one  by  Haultain,^  chorionic  villi 
with  actively  proliferating  syncytium  are  embedded  in  the 
malignant  mass,  and  the  syncytial  masses  in  the  tumour  can  be 
traced  as  continuous  with  the  proliferating  syncytium  of  the  villi. 
These  cases  seem  to  represent  the  initial  stage  of  the  growth,  and 
constitute  the  most  decisive  proof  of  its  origin  from  the  foetal 
epithelium.  Further  evidence  is  found  in  the  fact  that  in 
Neumann's^  case  and  in  some  others,  chorionic  villi  have  been 
found  in  metastases,  as  well  as  in  the  original  growth.  In  a  case 
recorded  by  Apfelstadt  and  Aschoff,^  the  secondary  growth  in  the 
labium  and  paravaginal  tissue  consisted  of  a  vesicular  mole,  with 
the  usual  stalks  and  cysts.  Metastasis  of  a  vesicular  mole  to  the 
lung  has  also  been  recorded,  and  metastasis  in  the  vagina  from  a 
vesicular  mole,  not  ultimately  running  a  malignant  course,  and 
without  any  disease  remaining  in  the  uterus.  These  latter  cases 
seem  to  indicate  a  malignant  or  semi-malignant  transformation  of 
the  cellular  tissue  stroma  as  well  as  of  the  epithelium  of  the  chorion. 

(2)  In  the  majority  of  cases,  the  structure  is  that  shown  in 
Fig.  496.  It  is  made  up,  in  about  equal  j)arts,  of  syncytium, 
generally  in  large  branching  masses,  and  masses  of  discrete  cells. 
Large  spaces  containing  blood  are  a  marked  feature  of  the  growth, 
and  the  syncytium  appears  to  lay  open  the  blood-vessels  in  a 
manner  which  has  been  compared  to  the  function  of  the  syncytium 
in  the  development  of  the  normal  placenta.  Malignant  cells  have 
been  found  in  thrombi  within  the  vessels.  In  the  growing  margin, 
where  the  growth  is  infiltrating  the  muscular  wall,  cells  or  groups 
of  cells  appear  to  have  a  special  tendency  to  penetrate  the  venous 
sinuses  and  engraft  themselves  on  the  interior  of  their  walls.  In 
this  way  is  accounted  for  the  very  rapid  formation  of  metastatic 
deposits,  which  occur  generally  through  the  vessels  and  not  through 
the  lymphatics,  and  especially  in  the  lungs.  There  is  a  marked 
tendency  to  necrosis,  and,  in  the  typical  part  of  the  tumour,  there 
are  no  vessels  among  either  cells  or  syncytium.  In  the  infecting 
margin,  however,  small  groups  of  cells,  or  small  masses  of  syncytium, 

1  See  Journ.  of  Brit.  Gyn.  Soc,  July,  1899  ;  and  for  figures  illustrating  this  form  of 
growth,  'i'eaclier,  'J'ran.s.  Ol)st.  Soc.  London,  1903,  Vol.  XLV.,  p.  25G. 

2  Verh.  d.  Ueutsch.  Gesell.  f.  Gyn.,  1891,  p.  341. 
'■'  Arch.  f.  Gyniik,,  1890,  p.  511. 


io66  The  Practice  of   Midwifery. 

even  as  small  as  single  cells,  appear  to  be  springing  up  in  the 
stroma,  so  that  this  part  of  the  growth  may  approximate  in  character 
to  the  third  variety,  next  to  be  described. 

(3)  In  comparatively  rare  cases,  generally  of  an  advanced  kind, 
where  the  patient  has  died  from  the  disease  without  operation, 
there  is  found  no  considerable  development  or  branching  processes 
of  syncytium,  but  only  comparatively  small  masses  of  nucleated 
protoplasm,  combined  with  a  large  proportion  of  discrete  cells. 
No  doubt  these  small  protoplasmic  masses,  which  have  the  staining 
qualities  of  syncytium,  really  are  syncytium,  and  this  variety  is 
developed  out  of  the  second,  the  more  typical  portions  of  the  growth 
having  become  necrosed. 

If  the  syncytium  of  the  villi  in  retained  placenta  after  abortion 
(Figs.  282,  283,  p.  520),  and  in  vesicular  mole  (Fig.  287,  p.  527), 
is  compared  with  Fig.  496,  there  appears  to  be  a  gradation 
toward  the  structure  seen  in  the  so-called  deciduoma  malignum  : 
and  an  intermediate  stage  between  Fig.  287  and  Fig.  496  is 
furnished  by  cases  in  which  chorionic  villi  are  present  in  the 
malignant  growth,  such  as  that  figured  by  Haultain. 

The  author  met  with  one  case,  before  chorionepifchelioma  had 
attracted  attention,  in  which  a  woman,  near  the  usual  time  of  the 
menopause,  had  a  vesicular  mole.  This  was  followed  within  a  few 
weeks  by  an  intra-uterine  growth,  which  bled  freely,  and  discharged 
gelatinous  masses  j^er  vaginum.  Sections  of  the  growth  had  the 
structure  of  myxoma,  and  no  chorionic  villi,  degenerated  or  other- 
wise, were  present.  For  some  months  the  growth  appeared  to  be 
running  a  malignant  course,  but  eventually,  after  repeated  clearing 
out  and  curetting  the  uterus,  it  died  out,  the  menopause  became  estab- 
lished, and  the  patient  has  remained  over  sixteen  years  free  from 
recurrence.  This  appears  to  have  been  probably  an  im23lantation 
of  myxoma  from  the  stroma  of  the  degenerated  villi ;  and  it  is 
notable  that  it  did  not  show  the  malignancy  of  chorionepithelioma. 
Every  possible  gradation  can  be  met  with  between  a  normal 
placenta,  a  hydatidiform  mole,  and  a  chorionepithelioma,  and,  in 
the  present  state  of  our  knowledge,  we  have  no  certain  criterion  by 
which  we  can  distinguish  between  a  benign  and  a  malignant  growth 
originating  in  the  epithelial  elements. 

In  a  few  cases  chorionepithelium  has  been  described  as  occurring 
in  the  Fallopian  tube  as  a  sequel  of  tubal  pregnancy.  In  one  of 
these,  recorded  by  Ahlfeld,  the  patient  was  aged  only  17.  It  has 
also  been  met  with  in  the  ovary. 

Early  metastasis  is  a  feature  in  all  the  varieties  of  growth,  and 
the  metastatic  growths  have  a  similar  microscopic  appearance  to 


Thrombosis,    Embolism,   Sudden   Death.      1067 

the  primary.  Deposits  have  been  observed  in  the  lungs  in  more 
than  70  per  cent,  of  the  cases.  In  over  50  per  cent,  there  were 
metastases  in  the  vagina  or  vulva.  They  also  occur  less  frequently 
in  the  kidneys,  spleen,  ovaries,  liver,  and  brain.  Free  hsemorrhage 
takes  j)lace  into  the  growths.  They  also  break  down  easily,  and 
hence  septicsemic  complications  occur  early.  Death  sometimes 
takes  place  through  thrombosis  or  embolism. 

In  a  considerable  number  of  the  cases,  as    with   hydatidiform 
moles,  there  appears  to  be  an  excess  of  lutein  tissue  in  the  ovary. 


Fig.  498. — Chorionepithelioma  of  uterus  with  secondary  growths  in  vao-ina 
and  in  perivaginal  connective  tissue. 


and  lutein  cysts  occur  (see  Fig.  495).  It  has  been  suggested  that 
this  excess  of  lutein  cells  plays  a  part  in  the  production  of  these 
growths,  but  it  seems  more  probable  that  both  conditions,  namely, 
the  excessive  proliferation  of  the  epithelial  elements  in  the 
chorionepithelioma  and  the  excessive  production  of  the  lutein 
cells,  may  in  reality  be  due  to  a  common  etiological  factor,  the  exact 
nature  of  which  is  at  present  unknown.  It  must  be  remembered 
that  even  in  normal  pregnancy  there  is  a  considerable  formation 
of    lutein  cells  in  the  ovary. 

Symptoms  and  Course. — The   characteristic  symptom  is  irre- 
gular hsemorrhage  commencing  within  a  few  weeks  after  delivery  or 


io68  The  Practice  of   Midwifery. 

abortion,  or  vesicular  mole.  Later  there  is  anaemia  with  pyrexia, 
rigors,  and  other  symptoms  of  saprsemia  or  septicaemia.  Some- 
times masses  of  growth  are  discharged.  Before  death  there  may 
be  evidence  of  affection  of  the  lungs,  and  frequently  metastatic 
growths  appear  in  the  genital  canal. 

Diagnosis. — In  case  of  haemorrhage  persisting  after  delivery, 
abortion,  or,  still  more,  after  vesicular  mole,  no  time  should  be  lost 
in  exploring  and  curetting  the  cavity  of  the  uterus.  Microscopic 
examination  should  be  made  of  any  masses  brought  away,  and 
in  the  examination  of  the  sections  stress  must  be  laid  upon  the 
presence  of  large  conglomerations  of  cells,  syncytial  or  ectodermal 
in  character,  displacing  portions  of  the  tissues,  together  with  the 
destruction  of  blood-vessels,  the  occurrence  of  haemorrhages,  and 
widespread  necrosis. 

Treatment. — The  only  hope  of  cure  is  in  very  early  hysterectomy, 
which  may  be  carried  out  by  the  vaginal  method,  or  preferably  by 
the  abdominal  route.  Metastatic  growths  in  the  vagina  or  vulva, 
if  limited,  may  be  removed  at  the  same  time.  In  a  certain  number 
of  cases  the  patients  have  remained  free  apparently  from  recurrence 
after  such  an  operation.-^  Cases  occurring  after  a  normal  pregnancy 
appear  to  be  more  fatal  and  more  rapid  in  their  growth  than  those 
following  a  hydatidiform  mole.  The  prognosis  is  favourable  if 
hysterectomy  is  performed  before  the  appearance  of  metastases  ; 
but  in  some  cases  these  have  appeared  afterwards,  and  led  to  a 
fatal  result  within  nine  months  from  the  operation.  In  a  few  cases 
metastases   have   died  out,  and   the   patient   has   recovered  after 

1  The  most  important  cases  of  chorionepithelioma  will  be  found  in  the  following 
papers  : — Chiari,  Wiener  Med.  Jahrb.,  1877,  p.  364  ;  Sanger,  Zentralbl.  f.  Gyniik.,  1889, 
p.  132  ;  Arch.  f.  Gyn.,  1893,  Vol.  XLIX.,  s.  89  ;  Gottschalk,  Arch.  f.  Gynak., 
Vol.  XLVL,  p.  1  ;  Marchand,  Monatsschr.  f.  Geb.,  1895,  Vol.  I.,  pp.  419  and  513  ; 
Zeitschr.  f.  Geb.  n.  Gyn.,  1898,  Vol.  XXXIX.,  p.  173;  Whitridge  Williams,  Johns 
Hopkins  Hospital  Reports,  1895,  Vol.  IV.,  No.  9  ;  Neumann,  Monatsschr.  f.  Geb.,  1896, 
Vol.  IV.,  p.  387,  1897,  Vol.  VI.,  p.  17  ;  Spencer,  Morison  and  Malcolm,  with  discussion 
on  papers,  Trans.  Obst.  Soc.  London,  1896,  Vol.  XXXVIII.,  p.  125  ;  Ahlfeld, 
Monatsschr.  f.  Gyn.,  Vol.  I.,  p.  209  ;  Ghrobak,  Zentralbl.  f.  Gyn.,  1896,  p.  1281  ;  Kelly 
and  Teacher,  Journ.  Path,  and  Bact.,  October,  1898  ;  Levvers,  Trans.  Obst.  Soc. 
London,  1897,  Vol.  XXXIX.,  p.  246  ;  Veit,  Handbuch  f.  Gyn.,  1899,  Vol.  III.,  p.  535  ; 
Zeitschr.  f.  Geb.  u.  Gyn..  1901,  Vol.  XLIV.,  p.  466  ;  Teacher,  Trans.  Obst.  Soc.  London, 
1903,  Vol.  XLV.,  p.  256  ;  Pierce,  Am.  Journ.  Obst.,  1902,  p.  321  ;  Ladinski,  Am.  Journ. 
Obst.,  1902,  p.  465;  Haultain,  Journ.  Brit.  Gyn.  Soc,  1899  ;  Schmauch,  Surgery,  Gyn, 
and  Obstet.,  September,  1907  ;  Kromer,  Deut.  Med.  Wochenschr.,  1907,  Vols.  XXXI.— 
XXXIII.  ;  Eden,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  1907,  Vol.  XII.,  No.  6, 
p.  424  ;  Fairbalrn,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  1909,  Vol.  XVI.,  No.  1,  p.  1  ; 
Rlsel,  IJber  das  Maligne  Chorionepitheliome,  Leipzig,  1903  ;  Frank,  New  York  Med. 
Journ.,  1906,  Vol.  LXXXIIL,  p.  864  ;  Hermann,  Beit,  zur  Geb.  u.  Gyn.,  1904, 
Vol.  VIIL,  p.  418. 


Thrombosis,    Embolism,   Sudden   Death.     1069 

hysterectomy.  Chrobak  and  Von  Franque  have  recorded  such 
cases,  in  which  there  had  been  sanguineous  sputa  and  other  symp- 
toms pointing  to  a  metastasis  in  the  lungs.  In  a  case  recorded 
by  Veit,  a  mass  supposed  to  be  a  metastasis  in  the  iHac  fossa 
eventually  disappeared.  Metastases  having  the  structure  of  vesi- 
cular mole  have  disappeared  after  merely  scraping  out. 


Chapter   XLL 
PUERPERAL  INSANITY* 

Puerperal  insanity  may  be  divided  into  four  classes  : — the 
insanity  of  pregnancy,  that  of  labour,  that  of  the  puerperal  state, 
and  that  of  lactation.  The  imj)ortant  influence  which  child-bearing 
has  in  reference  to  mental  diseases  is  proved  by  the  notable  pro- 
portion of  patients  admitted  to  lunatic  asylums  in  which  the  disease 
is  attributed  to  this  cause.  By  various  authors  this  proportion  is 
estimated  at  from  8  to  12  per  cent.  At  Bethlem  Hospital,  out  of 
1,333  female  patients  admitted  from  the  year  1864  to  1874  inclusive, 
14*7  per  cent,  owed  their  insanity  more  or  less  to  causes  related  to 
pregnancy  or  childbirth.^  The  report  of  the  Lunacy  Commissioners 
for  the  year  1902  shows  that  among  women  of  all  ages  the  yearly 
average  number  of  admissions  into  asylums  for  the  years  1896  to 
1900  due  to  puerperal  insanity  bears  the  percentage  of  6*4  in  the 
private  class  and  of  8*1  per  cent,  in  the  poorer  classes  to  the  total 
yearly  average  of  admissions  from  all  causes.^  It^  is  to  be  remem- 
bered, moreover,  that  most  of  the  milder  and  more  temporary  forms 
of  disease  are  treated  at  home. 

Puerperal  insanity  may  assume  any  of  the  forms  of  insanity  in 
general.  The  only  peculiarity  about  it  is  its  relatively  good  prog- 
nosis. This  is  another  circumstance  proving  the  veritable  character 
of  the  influence  exercised  by  pregnancy;  for  after  the  effect  pro- 
duced by  this  exciting  cause  has  died  away,  cure  results  in  the  great 
majority  of  cases  ;  and  thus,  in  this  respect,  puerperal  insanity  is  in 
contrast  to  insanity  in  its  other  forms.  Not  every  case,  however,  of 
insanity  occurring  during  pregnancy  or  after  delivery  has  those 
conditions  for  its  cause. 

Puerperal  insanity  resembles  other  forms  of  the  disease  in  that 
hereditary  tendency  is  of  great  importance  as  a  predisposing  cause. 
From  this  point  of  view  must  be  taken  into  account  the  occurrence 
in  relations,  not  only  of  actual  insanity,  but  of  other  neuroses,  such 
as  hysteria,  epilepsy,  chorea,  and  the  like.  Savage  found  distinct 
acknowledged  insanity  in  the  family  in  31*4  per  cent,  out  of  207 

1  Savage,  "  Observations  on  the  Insanity  of  Pregnancy  and  Childbirth,"  Guy's  Hosp. 
Eep.,  Third  Series,  Vol.  XX. 

2  Jones,  Journ.  Obst.  and  Gyn.  Brit.  Emp.,  190H,  Vol.  III.,  No.  2,  p.  109. 


Tuke. 

Weber. 

Jones. 

18 

15 

21*6  per  cent. 

47 

58 

46-3        „ 

35 

26 

32-4        „ 

Puerperal   Insanity.  107 1 

cases ;  Eeed  in  40*5  per  cent,  out  of  111 ;  Tuke  in  31-5  per  cent,  out 
of  78  ;  Hellyt  in  38*8  per  cent,  out  of  131  ;  Jones  in  nearly  50  per 
cent,  out  of  259.  In  about  as  many  more  cases  a  history  of  some 
other  neuroses  in  the  family  may  be  discovered. 

Of  the  three  principal  forms  of  puerperal  insanity,  namely,  those 
of  pregnancy,  the  puerperal  period,  and  lactation,  the  insanity  of 
pregnancy  is  the  rarest,  and  that  of  the  puerperal  period  the 
commonest.  The  following  are  the  proportions  according  to  various 
authors  : — 

Marce. 
Insanity  of  pregnancy        .         .       8 
Insanity  of  the  puerperal  period     58 
Insanity  of  lactation  .         .         .33 

In  all  the  forms  of  puerperal  insanity  there  is  generally  associa- 
tion with  debility,  exhaustion,  or  impoverishment  of  blood.  In 
all  of  them  some  mental  impression,  such  as  a  bereavement, 
fright,  sudden  bad  news,  anxiety  about  children,  or  quarrel  with 
relatives,  may  be  the  exciting  cause  of  the  outbreak.  Thus,  in 
times  of  war  and  revolution  puerperal  insanity  is  more  common 
than  usual. 

In  all  the  varieties,  but  especially  in  the  insanity  of  pregnancy, 
occurring  in  single  women  in  25  per  cent.,  and  that  of  the 
puerperal  period,  the  grief  and  shame  of  seduction  form  an 
important  predisposing  cause  in  many  cases.  Another  cause, 
which  may  be  met  with  in  each  division,  is  rapid  child-bearing. 
The  exhaustion  of  repeated  child-birth  and  lactation  may  be 
sufficient  to  call  a  predisposition  into  activity,  especially  if  there 
is  hereditary  taint.  Septic  infection  is  also  an  important  factor  in 
many  cases. 

To  all  the  forms  of  insanity,  but  especially  to  those  of  pregnancy 
and  the  puerperal  state,  primiparge  are  most  liable.  On  the  other 
hand,  increase  of  age  increases  the  proclivity.  Thus  between  the 
ages  of  20  and  30,  about  70  per  cent,  of  the  births  take  place, 
but  only  56  per  cent,  of  the  cases  of  insanity  occur  then  ;  between 
the  ages  of  30  and  40,  20  per  cent,  of  the  births  take  place,  but 
35  per  cent,  of  the  cases  of  insanity  occur ;  less  than  1*5  per  cent, 
of  the  births  take  place  after  the  age  of  40,  whereas  8*6  per  cent,  of 
the  cases  of  insanity  occur  after  that  age  (Marce).  In  some  cases 
insanity  has  been  developed  in  the  puerperal  period  after  a  first 
pregnancy  ;  while  on  a  second  occasion,  it  has  come  on  during 
pregnancy,  thus  apparently  indicating  a  progressive  vulnerability 
under  the  influence  of  the  disturbing  cause. 


1072  The  Practice  of   Midwifery. 

Tyler  Smith^  relates  the  case  of  a  patient  who,  out  of  seven 
deliveries,  had  twins  three  times.  On  each  of  these  three  occasions 
she  suffered  from  puerperal  mania. 

The  Insanity  of  Pregnancy.  — The  tendency  of  pregnancy  to 
call  into  activity  other  neuroses,  such  as  hysteria  and  chorea,  has 
already  been  described.  It  is  accounted  for  partly  by  the  presence 
of  a  local  source  of  reflex  irritation,  partly  by  the  increase  in  preg- 
nancy of  the  irritability  of  the  nerve  centres  to  prepare  them  for  the 
work  of  parturition.  The  influence  of  pregnancy  with  regard  to 
insanity  must  be  explained,  in  part,  in  the  same  way.  The  well- 
known  unnatural  longings  of  pregnancy  may  also  be  regarded  as 
having  some  relation  to  insanity  ;  for  in  some  cases  these  proceed 
to  such  a  length  as  to  amount  to  moral  perversion,  as,  for  instance, 
when  they  take  the  form  of  dipsomania  or  kleptomania. 

The  anaemia  and  deterioration  of  blood  which  are  not  uncommon 
in  pregnancy  may  often  have  to  do  with  the  causation.  In  some 
instances  albuminuria,  or  the  blood  changes  resulting  from  jaundice, 
have  been  regarded  as  a  cause. 

A  mental  cause  frequently  present  is  the  fear  or  conviction,  so 
commonly  met  with  in  pregnant  women,  especially  those  pregnant 
for  the  first  time,  that  the  result  of  delivery  will  be  fatal.  In  many 
cases  the  development  of  melancholia  out  of  this  despondent  frame 
of  mind  can  be  traced.  It  is  a  further  proof  of  the  relation  between 
the  two  conditions  that  the  insanity  of  pregnancy  takes  the  form  of 
melancholia  in  the  great  majority  of  cases.  Out  of  28  cases 
recorded  by  Tuke,  there  was  melancholia  in  20,  typical  mania  in 
only  2  ;  out  of  10  recorded  by  Savage,  there  was  melancholia  in  7, 
and  typical  mania  in  only  1. 

With  the  melancholia  more  or  less  of  dementia  is  associated  in  a 
minority  of  the  cases.  Disposition  to  suicide  is  strong.  If  the 
insanity  persists  after  delivery,  there  may  be  a  homicidal  tendency 
towards  the  infant.  There  may  be  refusal  of  food,  and  the  delusion 
that  attempts  are  being  made  to  poison  is  not  uncommon.  There 
is  generally  apathy  and  indiiference  towards  husband  and  friends. 
Erotic  manifestations  are  comparatively  uncommon.  The  tendency 
to  moral  perversions,  such  as  dipsomania  and  kleptomania,  some- 
times without  other  evidence  of  insanity,  has  been  already  men- 
tioned. Insanity  may  come  on  at  any  time  during  pregnancy,  but 
generally  after  the  second  or  third  month,  the  largest  proportion 
occurring  after  the  fifth  month. 

Prognosis. — The  great  majority  of  patients  recover,  but  usually 

1  Manual  of  Obstetrics. 


Puerperal    Insanity.  i073 

not  till  after  delivery.  In  a  few  instances,  however,  when  insanity 
comes  on  in  the  early  months,  the  patient  recovers  before  delivery. 
There  is,  however,  a  liability  to  relapse  after  delivery.  According 
to  Spiegelberg,  the  prognosis  is  more  favourable  when  the  insanity 
comes  on  in  the  early  months.  Of  Savage's  cases,  90  per  cent, 
recovered  within  twelve  months.  The  average  date  of  recovery 
was  six  months  after  delivery.  When  the  insanity  takes  a  form 
different  from  that  usual  during  pregnancy — that  is  to  say,  when 
there  is  mania  rather  than  melancholia  —  the  prognosis  is  less 
favourable. 

The  Insanity  of  Labour. — In  some  cases  of  labour  a  kind  of 
transitory  mania  or  delirium  is  produced  by  the  intensity  of  the 
pain.  The  patient,  in  her  frenzy,  may  injure  herself,  or,  more 
frequently,  injure  the  child,  the  excitement  reaching  its  height 
just  at  the  final  pains,  when  the  head  passes  the  vulva.  As  might 
be  expected,  this  is  more  common  in  primiparae,  in  whom  greater 
pain  is  produced  in  the  distension  of  the  perineum,  and  inevitable 
laceration  of  the  vaginal  outlet.  The  mental  agony  resulting  from 
seduction  may  add  to  the  effect.  There  is  a  medico-legal  interest 
in  the  question,  since  it  has  generally  been  held,  when  a  woman  has 
been  delivered  alone,  and  is  accused  of  having  committed  infanticide 
immediately  upon  the  birth  of  the  child,  that  the  deed  may  have 
been  done  under  the  influence  of  transient  mania.  As  a  rule,  the 
maniacal  excitement  passes  off  as  soon  as  the  child  is  born,  and  it 
may  therefore  be  questioned  whether  this  transient  frenzy  should 
really  be  classed  as  insanity.  There  is  a  resemblance,  however,  to 
insanity  in  the  fact  that  delusions  are  sometimes  manifested. 
Moreover,  in  a  few  cases,  though  the  excitement  passes  off  for  a 
time,  other  mental  symptoms,  such  as  melancholia,  are  developed 
a  little  later.  The  maniacal  excitement  must  then  be  regarded  as 
the  first  symptom  of  the  disease.  Two  cases  of  this  kind  are 
recorded  by  Savage. 

The  Insanity  of  the  Puerperal  Period. — This,  as  already 
explained,  is  the  most  common  form  of  puerperal  insanity.  There 
is  no  positive  line  of  demarcation  between  it  and  the  insanity  of 
lactation,  but  it  is  generally  regarded  as  including  all  cases  occur- 
ring within  two  months  after  delivery.  Of  these,  the  great  majority, 
about  90  i^er  cent.,  are  developed  within  the  first  fortnight,  and 
extremely  few  after  the  first  month.  The  insanity  of  lactation,  on 
the  other  hand,  usually  comes  on  when  the  patient  has  been 
weakened  by  many  months'  nursing. 

M.  68 


I074  The  Practice  of   Midwifery. 

Causation. — Besides  the  general  causes  already  enumerated  (see 
p.  1071),  the  chief  causes  operating  in  the  production  of  this  variety 
are  the  effect  upon  the  nervous  system  produced  by  the  shock  of 
labour  and  the  subsequent  exhaustion.  The  disease  is  therefore 
promoted  by  anything  which  increases  either  of  these  effects, 
especially  difficult  or  painful  labour,  or  excessive  haemorrhage. 
Anaemia  is,  indeed,  almost  always  a  marked  feature  in  the  patient. 
Some  mental  impression,  such  as  grief  at  the  loss  of  a  child,  is 
present  in  a  large  proportion  of  cases  (46  out  of  92,  according  to 
Esquirol).  The  shame  resulting  from  seduction  has  an  important 
influence  according  to  some,  but  Savage  has  found  insanity  after 
illegitimate  childbirth  to  be  comparatively  rare. 

In  some  cases  of  neurotic  patients,  or  those  predisposed  to 
insanity,  the  delirium  accompanying  some  form  of  puerperal  fever 
takes  a  maniacal  aspect.  The  delirium  then  varies  in  proportion 
to  the  fever,  and  subsides  with  it.  In  other  cases,  again,  the 
puerperal  fever  appears  to  be  the  starting-point  of  the  insanity, 
just  as  any  other  kind  of  acute  disease  may  be.  The  insanity  then 
remains  after  the  pyrexia  has  subsided.  Other  acute  disorders, 
comjjlicating  the  puerperal  state,  which  have  been  observed  as  the 
antecedents  of  insanity,  are  rheumatic  fever,  scarlatina,  and 
mammary  abscess. 

Sir  J.  Simpson  held  that  puerperal  insanity  was  frequently  the 
result  of  ursemia,  but  other  authorities  have  found  albuminuria 
to  be  very  rarely  present.  Savage,  however,  records  a  case  in 
which  slight  albuminuria  was  present  only  during  the  period  of 
excitement,  a  condition  not  found  in  ordinary  acute  mania.  Sir  J. 
Simpson,  indeed,  stated  that  the  albumen  disappeared  from  the 
urine  within  a  short  time  after  the  access  of  the  malady ;  but,  in 
such  case,  the  insanity  can  hardly  be  regarded  as  ursemic. 
Insanity  has  occasionally  been  a  sequel  of  eclampsia,  but  only  in 
rare  cases. 

Puerperal  insanity  may  occur  after  an  abortion  as  well  as  after 
labour,  although  not  so  frequently.  Sometimes  it  recurs  in 
successive  pregnancies.  In  other  cases,  after  a  first  attack  of 
puerperal  mania,  some  uterine  disorder,  or  an  ovarian  tumour,  may 
cause  a  recurrence.  I  have  known  very  acute  mania,  resembling 
puerperal  mania,  and  followed  by  rapid  recovery,  to  be  the  sequel 
of  the  operation  for  the  incision  of  the  cervix  uteri. 

Clinical  Course. — In  the  majority  of  cases  the  form  taken  is  that 
of  mania  (in  57  out  of  73  cases,  according  to  Tuke).  This  is 
especially  the  case  when  the  outbreak  takes  place  within  a  fort- 
night after  delivery.      There  "may  be  premonitory  signs  of  mental 


Puerperal   Insanity.  1075 

disturbance.  Generally  there  is  sleeplessness ;  the  patient  may  take 
an  unreasonable  dislike  to  the  nurse,  or  alter  in  her  manner  to  her 
husband.  The  maniacal  outbreak  may  be  sudden.  Generally  it  is 
marked  by  extreme  restlessness  of  motion  and  incoherent  voluble 
speech.  Throughout  the  incoherence  may  be  sometimes  traced  a 
prominent  delusion,  or  some  idea  which  had  previously  occupied 
the  patient's  mind.  Hallucinations  of  vision  are  frequent.  The 
patient  may  violently  resist  being  kept  in  bed,  may  tear  off  her 
clothes,  or  try  to  throw  herself  out  of  the  window.  She  is  often 
violent  towards  relations,  takes  a  dislike  to  her  hu'sband,  and  is 
apt  to  try  to  destroy  the  child.  The  suicidal  tendency  is  also 
often  marked.  In  a  few  cases  the  mania  comes  on  very  suddenly — 
within  a  few  days  after  delivery — and  passes  off  as  suddenly. 
Patients  in  this  state  may  destroy  their  children  or  injure  them- 
selves or  others,  and  the  explosion  may  suddenly  restore  the 
balance  of  reason.  The  condition  is  therefore  one  of  medico-legal 
importance. 

In  other  cases  the  onset  is  not  so  violent.  The  patient  at  first 
may  merely  be  incoherent,  may  refuse  food,  or  may  show  signs  of 
delusion ;  but,  in  all  cases  which  occur  within  the  first  fortnight 
after  delivery,  an  outbreak  of  violence  is  to  be  apprehended. 

The  pulse  is  rapid  when  excitement  is  present,  but  the  tempera- 
ture is  not  generally  elevated,  unless  the  insanity  is  dependent  upon, 
or  associated  with,  some  other  cause  of  pyrexia,  such  as  septic 
disturbance.  The  tongue  is  usually  coated,  and  the  bowels  often 
constipated.  Evacuations  may  be  passed  involuntarily,  or  without 
regard  for  decency.  There  may  be  filthy  habits,  such  as  eating 
excrement.  Food  is  often  refused.  The  urine  is  scanty,  and  con- 
tains excess  of  urea,  urates  and  phosphates,  in  consequence  of  the 
increased  waste  of  tissues.  The  lochia  and  secretion  of  milk  are 
generally  suppressed  or  diminished  at  the  outset  of  the  disease. 
This  circumstance  is  to  be  regarded,  as  a  rule,  as  a  consequence, 
and  not  a  cause  of  the  insanity.  Sometimes,  however,  especially 
within  the  first  week,  it  may  indicate  a  septic  disturbance,  which 
is  itself  exciting  the  insanity.  It  will  then  be  associated  with 
elevation  of  temperature.  The  incessant  restlessness  of  body  and 
mind,  sleeplessness,  and  difficulty  about  feeding  often  lead  to  great 
wasting,  and  increase  of  that  ansemia  which  is  usually  present  from 
the  first. 

An  erotic  tendency  is  rather  common,  and  women  may  use  in 
their  ravings  obscene  and  profane  language  with  which  they  would 
hardly  have  been  thought  likely  to  be  acquainted.  Delusions 
of  a  sexual  kind  may  be  prominent,  and  the  patient  may  falsely 

68—2 


1076  The  Practice  of   Midwifery. 

accuse  herself  of  unchastity.  Masturbation  is  pretty  frequent. 
This  tendency  may  be  associated  with  the  fact  that  the  exciting 
cause  of  the  disease  is  an  affection  of  the  genital  organs.  It  is  apt 
to  persist  throughout  its  whole  course. 

I  have  met  with  a  case  in  which,  after  an  early  abortion,  and 
great  disappointment  in  consequence,  mania  took  the  form  of  intense 
paroxysms,  lasting  only  a  few  minutes,  like  epileptic  attacks,  and 
recurring  several  times  in  the  day.  In  the  paroxysm,  the  patient 
fought  furiously  with  those  present,  under  the  delusion  that  they 
were  devils  carrying  her  to  hell  to  prevent  her  having  a  child.  It 
passed  away  quite  suddenly,  and  she  lay  exhausted,  but  quite 
rational.  The  only  suspicious  sign  in  the  interval  was,  that  she 
wished  to  be  left  alone  with  one  of  her  children  and  a  knife,  in 
order  to  prove  that  she  was  quite  sane.  This  patient  had  to  be 
removed  to  an  asylum,  but  recovered  after  a  few  weeks. 

Melancholia  is  more  common  in  cases  commencing  later  than  the 
first  fortnight  after  delivery,  and  the  onset  is  commonly  more 
gradual.  In  this  form  there  is  often  religious  despondency. 
Other  moral  causes,  such  as  grief,  ill-treatment,  or  poverty,  are 
also  more  frequently  operative  than  in  mania.  Sleeplessness  is 
even  more  marked  than  in  mania.  The  suicidal  tendency  is  strong, 
even  when  there  is  an  entire  absence  of  delusions.  It  is  also 
necessary  to  guard  against  infanticide.  There  is  rarely  any  erotic 
tendency  or  evidence  of  masturbation.  The  patients  usually 
suffer  from  constipation,  and  are  averse  to  taking  food,  either 
from  simple  want  of  appetite  or  from  delusions.  Patients  who 
show  maniacal  excitement  at  the  outset  of  the  disease  may 
afterwards  pass  into  melancholia  or  dementia. 

Prognosis. — The  patient  rarely,  according  to  Savage,  dies  from 
simple  exhaustion,  as  sometimes  happens  with  other  forms  of  acute 
mania,  but  this  result  does  occasionally  follow.  The  chief  causes 
of  death  were  found  by  Savage  to  be  pyaemia  and  phthisis.  There 
were  7  deaths  in  78  cases  of  first  attacks  of  puerperal  mania 
recorded  by  him. 

Probably  the  fatal  cases  are  often  not  removed  to  asylums.  Of 
four  cases,  occurring  in  23,591  deliveries  in  the  Guy's  Hospital 
Lying-in  Charity,  all  proved  fatal ;  but  this  is  an  unusual  result. 
One  died  from  septicaemia,  of  which  the  mania  was  a  complication ; 
one  from  pneumonia ;  two  apparently  from  exhaustion.  In  one  of 
these  two  cases  there  was  albuminuria. 

If  the  patient  does  not  die,  cure  follows  in  the  great  majority  of 
cases.  It  may  still  be  hoped  for,  even  after  the  disease  has  per- 
sisted for  twelve  months.     Sometimes,  however,  the  patient  lapses 


Puerperal   Insanity.  1077 

into  permanent  melancholia  or  dementia.  Of  the  above  78  cases 
recorded  by  Savage,  13  patients  were  uncured  at  the  end  of  from 
12  to  18  months.  The  most  frequent  duration  is  from  three  to  six 
months.  A  larger  proportion  of  the  cases  with  a  sudden  onset 
recover  than  of  those  in  whom  the  onset  is  gradual.  In  recurrent 
attacks  the  prognosis  is  less  favourable,  and  the  cure  generally 
requires  longer  time.  In  melancholia  the  average  duration  is 
somewhat  longer.  The  greatest  number  of  recoveries  takes  place 
from  the  fourth  to  the  seventh  month. 

The  Insanity  of  Lactation. — This  form  of  insanity  is  com- 
moner among  the  poor  than  among  the  rich,  and  commences  in 
general  physical  weakness  and  anaemia.  It  is  most  frequent  in 
multiparse  who  have  been  weakened  by  numerous  or  quickly- 
repeated  pregnancies.  It  may  commence  at  any  time,  from  two 
months  up  to  eighteen  months  or  more  after  delivery.  In  a  few 
cases,  the  outbreak  has  followed  almost  immediately  upon  weaning. 
The  majority  of  patients  suffer  from  the  outset  from  melancholia, 
and,  even  of  those  who  are  excited  at  the  commencement,  almost 
all  become  melancholic  afterwards.  The  proportion  of  recoveries 
and  the  duration  of  the  disease  are  similar  to  those  in  the  insanity 
of  the  puerperal  period. 

Prophylaxis. — Marriage  should  be  discouraged  in  women  who 
have  a  strong  hereditary  disposition  to  insanity,  and  also,  in  most 
cases,  in  those  who  have  already  had  an  attack  of  insanity.  Such 
advice,  however,  will  generally  not  be  followed.  If  pregnancy 
occurs  in  such  women,  the  utmost  care  should  be  taken  to  main- 
tain the  health  by  nutritious  food  and  hygienic  management.  If  a 
patient  has  previously  suffered  from  the  insanity  of  pregnancy,  and 
has  premonitory  signs  of  mental  disturbance  in  a  subsequent  preg- 
nancy, the  question  of  inducing  abortion  with  the  hope  of  averting 
insanity  may  arise.  In  general,  this  proceeding  is  as  likely  to 
precipitate  the  insanity  as  to  avert  it,  and  as  the  hope  of  benefit  is 
not  enough  to  justify  the  sacrifice  of  the  child,  it  is  not  to  be 
recommended. 

Treatment. — As  the  disease  so  generally  terminates  in  recovery, 
it  is  desiral)le  to  avoid  sending  the  patient  to  an  asylum,  in 
order  to  avoid  the  consequent  stigma,  provided  that  she  is  in  a 
position  to  secure  the  services  of  skilled  attendants.  Since  she 
must  be  constantly  watched,  day  and  night,  two  attendants  at  least 
are  necessary.     In  cases  of  violent  mania,  four  may  be  required. 


loyS  The  Practice  of   Midwifery. 

With  patients  who  are  not  wealthy,  therefore,  removal  generally 
becomes  necessary,  unless  the  attack  is  mild,  and  of  brief  duration. 
If  removal  is  likely  to  be  necessary,  it  is  well  that  it  should  take 
place  early,  since  change  of  scene  and  complete  separation  from 
relations  often  have  a  beneficial  effect.  In  the  insanity  of 
pregnancy,  the  consideration  that  the  duration  is  likely  to  be 
longer  than  in  the  other  forms  may  be  an  element  in  the  decision. 

The  most  important  point  in  treatment  is  to  maintain  nutrition, 
and,  according  to  Jones,  the  essence  of  the  treatment  is  "  com- 
pulsory superalimentation."  If  possible,  the  patient  should  be 
induced  by  coaxing  to  take  an  ample  amount  of  solid  food.  If  this 
does  not  succeed,  liquids  must  be  given.  Forcible  administration 
of  food  may  be  necessary  in  melancholia,  and  sometimes  in  mania. 
The  best  plan  is  to  pass  through  a  nostril  a  long  thin  oesophageal 
tube  surmounted  by  a  funnel,  the  patient  being  placed  on  her  back. 
Gruel,  or  milk  thickened  with  some  farinaceous  food,  or  eggs  beaten 
up  with  milk,  may  be  poured  down.  In  acute  delirious  mania  the 
free  administration  of  alcohol  is  usually  indicated. 

Bromide  of  potassium  is  often  useful  in  the  early  stages  of  excite- 
ment. Hypnotics  must  be  used  freely,  as  it  is  of  the  utmost 
importance  to  procure  sleep  if  there  are  successive  restless  nights. 
Chloral  with  bromide  of  potassium  should  be  given,  and  sulphonal 
is  useful  when  there  is  much  motor  excitement.  Opium  and 
morphia  are  contra-indicated  as  a  general  rule.  In  melancholia, 
however,  opiates  often  act  better  than  in  mania.  Stimulants  in 
free  doses,  given  in  the  evening,  often  aid  sleep,  and  diminish  the 
necessity  for  hypnotics.  For  the  headaches,  which  are  often  very 
distressing,  antipyrin  and  potassium  bromide  may  be  ordered. 

It  is  desirable  that  the  patient  should  not  see  her  husband, 
children,  and  relatives,  especially  if  she  has  shown  any  dislike  to 
them.  In  the  later  stages,  change  of  air  and  scene  often  proves 
beneficial.  In  the  convalescent  stage.  Savage  considers  that  a 
return  to  cohabitation  is  beneficial,  but  pregnancy  should  be 
avoided  for  a  considerable  time. 


Chapter  XLII. 
INJURIES   AND    DISEASES  OF   THE   FCETUS. 

CBPHALHiEMATOMA. — Besides  the  caput  succedaneum  another 
form  of  swelling  on  the  head  may  result  from  difficult  labour, 
namely,  cephalhsematoma,  consisting  of  a  circumscribed  effusion  of 
blood.  Small  effusions  of  blood  may  take  place  in  the  substance  of 
the  caput  succedaneum,  that  is  to  say,  in  the  cellular  tissue  beneath 
the  scalp.  But,  in  the  characteristic  form  {cephalhematoma  externa), 
the  effusion  takes  place  beneath  the  pericranium,  separating  it  from 
the  bone,  and  is  due  to  the  rupture  of  a  considerable  vessel.  In 
some  cases,  blood  is  effused  also  beneath  the  bone  {cephalh(ematoma 
interna),  between  it  and  the  dura  mater.  The  bone  beneath  is  very 
congested,  and  not  infrequently  a  careful  examination  reveals  the 
presence  of  a  small  crack  or  fissure.  Cephalhaematoma  most 
frequently  results  from  the  pressure  of  the  blades  of  forceps  ;  but 
it  may  be  produced  by  pressure  against  any  projecting  bone,  such 
as  the  promontory  of  the  sacrum.  It  is  also  ascribed  to  the  effect 
of  pressure  produced  by  an  unyielding  os  uteri. 

The  occurrence  of  a  cephalhaematoma  is  no  doubt  to  be  ex- 
plained in  the  majority  of  cases  by  the  rupture  during  labour  of 
some  of  the  vessels  passing  from  the  pericranium  to  the  bones 
of  the  skull.  It  has  been  suggested,  however,  that  such  an  injury 
is  predisposed  to  by  the  presence  of  small  fissures  in  the  bones 
due  to  defective  ossification,  or  that  there  may  be  a  diseased 
condition  of  the  vessel  walls  present  rendering  them  more  readily 
torn.  Fere^  has  described  the  constant  presence  of  small  fissures 
at  the  postero-superior  angle  of  the  parietal  bone,  the  site  of  most 
frequent  occurrence  of  a  cephalhaematoma,  and  has  shown  that  a 
very  slight  pressure  on  the  head  will  cause  extension  of  these 
fissures  and  the  rupture  of  the  small  blood-vessels  crossing  them. 
In  some  such  manner  are  to  be  explained  the  cases  where  such  an 
effusion  of  blood  occurs  during  an  easy  and  normal  labour  or  in  a 
case  in  which  the  head  does  not  present. 

Diagnosis. — The  swelling  is  limited  to  one  bone,  generally  a 
parietal  bone,  more  frequently  the  right  than  the  left,  and  very 

1  Kcvuc  mens,  de  Mi^d.  ot  do  Chir.,  1880,  Vol.  IV.,  p.  112. 


io8o  The  Practice  of   Midwifery. 

rarely  it  occurs  upon  the  occipital,  frontal,  or  temporal  bones.  It 
continues  to  increase  for  a  time  after  birth,  while  a  caput  suc- 
cedaneum  diminishes  progressively  and  rapidly  from  the  time  of 
birth.  A  cephalhsematoma  is  generally  first  noticed  from  one  to 
four  days  after  birth.  It  may  increase  up  to  seven  days,  then 
remains  for  a  few  days  stationary ;  and  generally  has  disappeared 
after  from  four  to  twelve  weeks.  As  a  rule  there  is  no  discolora- 
tion of  skin  over  the  tumour.  The  tumour  never  crosses  a  suture, 
but  in  rare  cases  has  occurred  on  both  parietal  bones.  When  this 
occurs  the  two  tumours  are  generally  separated  from  one  another 
by  a  well-marked  groove.  The  swelling  is  painless,  and  fluctuation 
can  generally  be  felt  in  it,  until  the  serum  has  become  absorbed.  It 
may  or  may  not  extend  over  the  whole  bone.  After  four  or  five 
days  a  hard  border  of  inflammatory  material  begins  to  be  felt 
round  the  edge,  so  that  the  feel  somewhat  resembles  that  of  a 
depressed  fracture.  This  is  due  to  the  formation  of  bony  material 
along  the  edge  of  the  detached  pericranium.  From  this  a  thin 
crust  of  bone,  which  crackles  on  i3ressure,  may  extend  over  the 
swelling  during  the  time  in  which  the  serum  and  clots  are  being 
absorbed.  Encephalocele  is  distinguished  by  the  fact  that  it 
always  occurs  in  the  line  of  a  suture  or  at  a  fontanelle.  There 
is  no  fluctuation,  but  the  swelling  generally  pulsates,  and  enlarges 
when  the  child  cries.  A  vascular  tumour  of  the  scalp  gives 
no  fluctuation;  and  there  is  generally  discoloration  of  the  skin 
over  it. 

Prognosis. — In  general  the  effusion  is  absorbed  in  time.  But 
in  a  weakly  or  cachectic  child,  it  may  suppurate,  and  then  may 
endanger  life,  sometimes  leading  to  pj'semia. 

Treatment. — The  swelling  should  be  left  alone,  unless  there  is 
evidence  of  suppuration,  when  it  should  be  laid  open  and  the  sac 
packed  with  gauze. 

Other  Injuries  to  the  Head. — Among  the  rarer  injuries  as  the 
result  of  difficult  forceps  delivery  are  fractures  of  the  bones  of  the 
face,  of  the  nose,  or  of  the  orbit,  with  injuries  of  various  kinds  to 
the  eyes.  Occasionally  from  slipping  of  the  forceps  the  lobe  of  the 
ear  may  be  torn  partly  or  even  completely  off.  Injuries  to  the  eye, 
a  very  important  variety,  may  be  produced  directly  by  the  pressure 
of  the  blades  of  the  forceps  or  indirectly  from  the  compression  of 
the  head  or  as  a  result  of  fracture  of  the  bones  of  the  orbit.  These 
accidents  are  practically  limited  to  cephalic  presentations,  and  are 
never  met  with  when  the  child  has  presented  by  the  breech.  They 
vary  in  severity  from  slight  lacerations  of  the  eyelids  to  complete 


Injuries  and  Diseases  of  the  Foetus.     1081 

destruction  or  evulsion  of  the  eyes.      In  112  cases  of  this  kind 
collected  by  Wolff  ^  in  no  less  than  19  the  eyeballs  were  extruded 


Fig.  499. — A  spoon-shaped  depression  from  a  case  of  forceps  delivery 
in  a  flattened  pelvis. 


Fig.  5U0. — L-shaped  depression  from  a  case  of  forceps  delivery  in  a 
flattened  pelvis. 

from  the  orbits.  Such  an  accident  is  most  likely  to  happen  when 
high  forceps  are  applied  and  the  head  is  pulled  forcibly  past  a 
contracted  brim. 

1  Beitrage  z.  Augcnheilkunde  ;  Fcstschr.  f.  J.  Hirschbcrg. 


io82  The  Practice  of   Midwifery. 

Injueies  to  the  Bones. — As  a  result  of  excessive  traction  on 
the  head  dislocation  of  the  cervical  vertebrae  may  occur  or  separa- 
tion of  the  condyloid  processes  of  the  occipital  bone,  a  very 
uncommon  but  fatal  injury.  Local  depressions  on  the  head  are 
generally  due  to  the  pressure  of  the  sacral  promontory.  There  may 
be  either  a  spoon-shaped  depression,  or  a  more  prolonged  groove. 
In  the  latter  case,  if  the  head  has  passed  in  a  position  of  flexion, 
the  groove  runs  downward  and  forward  near  the  anterior  border  of 
the  parietal  bone ;  if  in  a  position  of  moderate  extension,  the  groove 
is  nearly  parallel  to  the  coronal  suture.  In  some  cases  the  groove 
first  runs  parallel  to  the  suture  and  then  turns  forward,  flexion 
having  supervened  upon  extension  at  an  intermediate  stage.      The 


N 


v>    ( 


Fig.  501. — Fracture  of  the  anterior  inferior  angle  of  the  parietal  bone  in  a 
case  of  forceps  delivery. 

position  of  the  groove  is  similar  in  pelvic  presentations,  except  that 
it  is  often  more  parallel  to  the  coronal  suture,  passage  in  the  extended 
position  being  relatively  commoner.  Depressions  the  most  serious, 
as  they  are  often  associated  with  fracture  of  the  inner  table,  are 
more  common  in  pelvic  presentations,  since  the  head  is  generally 
dragged  quickly  past  the  obstruction.  Fissures  of  the  bone,  or 
actual  fractures,  are  comparatively  rare,  but  these  again  occur  more 
frequently  in  pelvic  presentations. 

Fractures  of  the  bones  of  the  skull  are  occasionally  met  with 
after  spontaneous  delivery,  but  usually  they  are  the  result  of  the 
pressure  of  the  blades  of  the  forceps  or  of  that  of  the  sacral 
promontory.  In  delivery  by  forceps  a  depression  may  be  pro- 
duced by  the  promontory  of  the  sacrum  on  the  frontal  bone  ;  since 
in  the  application  of  the  forceps  the  long  diameter  of  the  head  is  apt. 


Injuries  and  Diseases  of  the  Foetus.      1083 

in  a  flattened  pelvis,  to  be  changed  from  a  tranverse  into  an  oblique 
position. 

In  flattened  pelves,  in  consequence  of  the  Naegele-obliquity,  the 
posterior  parietal  and  posterior  half  of  the  frontal  bone  are  generally 
more  flattened,  the  anterior  more  rounded  than  in  normal  labour, 
because  the  latter,  projecting  more  deeply  into  the  brim,  are  more 
unsupported.  In  general  there  is  a  "  shear  "  or  sliding  movement 
of  the  anterior  parietal  bone  upon  the  posterior  in  the  direction  of 
the  occiput,  but  this  must  be  produced  after  the  occiput  has  begun 
to  rotate  forward,  and  is  therefore  more  marked  in  the  generally 
contracted  pelvis.  Fractures  usually  result  in  the  death  of  the 
child,  but  in  cases  where  furrows  or  depressions  alone  aie  present 
the  child  generally  survives.  Very  frequently  the  depression  dis- 
appears spontaneously,  in  some  cases  it  is  corrected  or  remains 
without  symptoms,  and  in  other  cases  permanently  injurious 
sequelae  follow.  These  may  take  the  form  of  paralysis,  idiocy,  or 
epileptic  convulsions. 

Treatment. — An  attempt  may  be  made  to  squeeze  out  a 
depression  of  the  skull  by  compressing  the  head,  not  too  violently, 
in  the  opposite  diameter  to  that  in  which  the  depression  lies.  If 
this  fails,  and  the  depression  is  not  beginning  to  disappear  in  a 
day  or  two,  an  incision  may  be  made,  with  careful  antiseptic 
precautions,  along  the  nearest  edge  of  the  bone,  and  a  blunt 
elevator  passed  underneath  the  bone,  to  raise  the  depressed  part. 
Or  the  incision  may  be  made  through  the  bone  a  quarter  of  an 
inch  from  the  suture,  to  avoid  the  risk  of  cutting  the  dura  mater, 
which  is  adherent  at  the  sutures. 

An  ingenious  method  is  that  advocated  by  Hastings  Tweedy.  ^ 
The  sharp  point  of  a  bullet  forceps  is  bored  through  the  bone  at 
the  centre  of  the  depression.  The  shank  is  then  turned  at  right 
angles  to  the  bone  and  the  depressed  area  pulled  with  a  jerk  into 
position. 

Injueies  to  Nerves. — Facial  paralysis  is  generally  the  result  of 
pressure  by  one  blade  of  the  forceps  upon  the  seventh  nerve,  where 
it  emerges  from  the  stylo-mastoid  foramen.  There  is  also  a  central 
form  of  the  paralysis  usually  distinguishable  by  the  fact  that  it  is 
not  so  complete  as  the  peripheral ;  for  example,  the  infant  is  able 
to  close  the  eye,  and  in  this  variety  the  cause  is  to  be  found 
in  some  intranatal  trauma  to  the  nucleus  of  the  seventh  nerve  or 
in  some  antenatal  changes  in  the  brain.  In  the  peripheral  variety, 
sucking   is   usually   interfered   with,   but   the  paralysis  generally 

'  Jlotunda  Practical  Midwifery,  1908,  p.  'Ml. 


1084  The  Practice  of   Midwifery. 

disappears  within  from  six  to  eight  weeks.  In  the  central  variety 
or  in  the  rare  instances  in  which  the  nerve  is  completely  divided, 
the  paralysis  usually  remains  permanently. 

Paralysis  of  a  limb  may  result  from  injury  to  a  nerve  produced 
by  traction  upon  an  arm  or  leg,  especially  in  association  with 
fracture  of  the  bone.  It  is  generally  m,ore  prolonged  than  facial 
paralysis,  and  is  apt  to  be  followed  by  some  permanent  impairment 
of  power,  sometimes  by  contraction.  Paralysis  of  the  arm  from 
injury  to  the  fifth  and  sixth  nerves  of  the  brachial  plexus  (birth 
paralysis  or  Duchenne's  paralysis)  is  a  most  important  variety  of 
birth  injury,  and  is  most  commonly  the  result  of  traction  on  the 
arm  during  delivery  of  the  arms  and  head  in  breech  or  transverse 
presentations,  but  may  also  be  produced  by  forcible  traction  on 
the  forecoming  head.  The  infraspinatus,  deltoid,  brachialis  anticus, 
and  biceps  muscles  are  all  involved  and  the  arm  assumes  a 
characteristic  attitude.  It  hangs  limply  by  the  side,  cannot  be 
abducted,  the  forearm  is  extended  and  cannot  be  flexed,  and  the 
hand  cannot  be  completely  supinated.  The  prognosis  is  unsatis- 
factory. According  to  Bruns^  only  20  per  cent,  recover,  whereas 
66  per  cent,  of  similar  injuries  to  single  nerves  below  the  plexus 
undergo  spontaneous  cure. 

Treatment. — In  paralysis  either  of  the  face  or  a  limb,  gentle 
massage  may  be  used  after  some  weeks,  if  power  does  not  quickly 
return.  Later,  electricity  may  be  tried,  especially  in  the  case  of 
a  limb.  In  paralysis  of  the  arm,  if  marked  improvement  does 
not  occur  in  two  or  three  months,  the  plexus  may  be  exposed,  the 
perineural  cicatrices  removed,  and  the  nerves  resected.^ 

Cerebral  Haemorrhages. — Besides  the  haemorrhage  between  the 
bone  and  dura  mater,  which  sometimes  accompanies  ce]3hal- 
hsematoma,  intra-cranial  hsemorrhage  may  occur  indej)endently. 
Haemorrhage  into  the  substance  of  the  brain  is  uncommon  and  was 
met  with  only  once  in  a  normal  foetus  and  three  times  in  anen- 
cephalic  foetuses  in  130  autopsies  on  still-born  children  recorded  by 
Spencer.^  The  greater  part  of  the  haemorrhages  are  into  and 
beneath  the  arachnoid  and  pia  mater  and  occasionally  between  the 
dura  mater  and  the  bone.  Haemorrhages  into  the  membranes 
occurred  in  53,  or  40'7  per  cent.,  of  Spencer's  cases.  It  is  interest- 
ing to  note  that  among  his  cases,  in  every  case  in  which  forceps 
had  been  used  to  deliver  living  children  who  died  during  or  after 

1  Neurolog.  Zentralbl.,  November  16,  1902. 

2  See  Thorburn  :  "Obstetrical  Paralysis,"  Journ.  of  Obst.  and  Gyn.,  Brit.  Eaip., 
May,  1903,  p.  454. 

s  Trans.  Obstet.  See,  London,  1891,  Vol.  XXXIII.,  p.  265. 


Injuries  and  Diseases  of  the  Foetus.      1085 

birth,  haemorrhages  were  found.  In  the  production  of  these 
haemorrhages  he  lays  great  stress  on  softness  and  increased  mobility 
of  the  skull  bones  from  laxity  of  the  sutures,  and  more  especially 
the  mobility  of  the  lower  anterior  angle  of  the  parietal  bone  which 
lies  over  and  is  very  liable  when  unduly  mobile  to  exert  injurious 
pressure  on  the  great  anastomotic  vein.  In  some  cases  the  bleed- 
ing is  the  direct  result  of  injuries  to  the  sinuses,  usually  with  a 
fatal  issue,  while  in  others  the  haemorrhages  are  due  to  pressure  on 
the  skull  from  a  difficult  delivery  or  pressure  on  the  neck  of  the 
child.  Of  recent  years  a  certain  number  of  these  cases  have  been 
operated  upon  successfully,  but  there  is  always  great  difficulty  in 
determining  if  a  haemorrhage  exists  and  whether  it  is  unilateral  or 
bilateral. 

HEMATOMA  AND  MYOSITIS  OF  THE  Sterno-Mastoid. — This  iiijury  is 
relatively  more  common  in  pelvic  presentations,  but  it  occurs  also 
in  vertex  presentations.  In  the  former  it  is  especially  likely  to  be 
j)roduced  by  traction  upon  the  legs  or  body ;  in  the  latter  it  may  be 
due  to  extraction  by  forceps.  The  lump  is  often  not  observed  for 
some  days  after  birth.  It  is  at  first  soft,  consisting  of  blood  ;  later 
some  inflammatory  effusion  occurs  and  the  lump  becomes  harder, 
and  may  increase  for  a  time.  As  a  rule  the  lump  entirely  dis- 
appears in  from  four  to  eight  weeks  and  leaves  no  j^ermanent  effect ; 
but  in  some  instances  cicatricial  contraction  takes  place,  and 
torticollis  is  produced. 

The  other  sjDocial  injuries  which  may  be  produced  by  extraction 
in  pelvic  presentations  have  already  been  described  (p.  819). 


Asphyxia  Neonatorum,  or  Suspended  Animation  of  the 
New-born  Infant. 

Normally  the  new-born  infant  not  only  breathes  freely,  but  cries 
loudly,  immediately  after  its  expulsion.  The  deep  inspirations 
which  it  makes  in  crying  are  of  service  in  fully  expanding  for  the 
first  time  the  previously  airless  lungs.  The  cause  of  the  first 
inspiration  is  partly  that  the  aeration  of  the  blood  is  interrupted  by 
detachment  of  the  placenta,  which  leads  to  an  accumulation  of  CO2 
in  the  blood,  and  partly  that  the  cold  external  air  acts  as  a  reflex 
stimulus  upon  the  skin.  Under  certain  circumstances,  the  child 
is  born  apparently  lifeless,  or  in  a  state  of  suspended  animation, 
and  makes  no  attempt  to  breathe,  although  the  heart  is  still  beating 
to  some  extent.  In  other  cases,  it  makes  ineffectual  gasps  at 
intervals. 


io86  The  Practice  of   Midwifery. 

Causation. — There  are  two  main  causes  of  the  state  of  sus- 
pended animation  : — First,  interruption  of,  or  obstruction  to,  the 
aeration  of  the  blood  by  the  jDlacental  circulation  ;  secondly,  pressure 
upon  the  head.  Interference  of  aeration  of  the  blood  may  take 
place  in  various  ways.  The  placenta  (especially  when  praevia)  may 
be  partially  or  wholly  detached.  The  circulation  through  it  may  be 
imj)eded  by  prolonged  contraction  of  the  uterus,  especially  when  the 
liquor  amnii  has  long  escaped,  the  uterus  closely  grasps  the  child, 
and  has  passed  into  the  state  of  continuous  contraction.  The  funis 
may  be  compressed  when  prolapsed  or  coiled  round  the  neck,  or  in 
pelvic  presentations.  When  coiled  round  the  neck  it  may  be  com- 
pressed against  the  symphysis  pubis  during  the  birth  of  the  head. 
(See  p.  305.)  Circulation  may  also  be  impeded  by  pressure  upon  the 
thorax  or  neck  of  the  child,  especially  when  the  head  has  been 
expelled,  and  the  trunk  is  retained  within  the  vulva.  Again 
deficient  aeration  of  blood  may  be  the  result  of  preceding  anaemia, 
or  profuse  haemorrhage  from  the  mother,  and  may  be  promoted  also 
by  poorness  of  quality,  or  other  morbid  condition,  of  the  maternal 
blood  a^Dart  from  haemorrhage,  such  as  occur  in  eclampsia  or  uraemia. 

The  first  effect  of  deficient  aeration  of  blood  is  that  the  respira- 
tory centre  is  stimulated,  and  the  child  makes  futile  efforts  to 
breathe.  This  is  proved  by  the  fact  that,  in  many  cases,  mucus, 
meconium  and  liquor  amnii  are  found  post  mortem  to  have  been 
drawn  into  the  bronchi  and  lungs,  and  extravasations  of  blood  in 
the  lungs  to  have  been  j^roduced  by  the  suction  due  to  attempted 
inspiration.  It  is  under  such  circumstances  that,  in  rare  cases,  the 
vagitus  uterinus,  or  intra-uterine  cry,  of  the  child  has  been  heard, 
when  air  has  been  admitted  into  the  uterus  in  the  course  of  turning 
or  some  other  obstetric  operation.  The  child  being  unable  to 
obtain  air,  the  heart's  action  becomes  slower  and  gradually  fails, 
and  eventually  the  irritability  of  the  respiratory  centre  is  impaired 
or  destroyed  from  the  accumulation  of  CO2  and  a  lack  of  a  supply  of 
suitable  blood.  When  the  child  is  born  in  this  condition,  the 
stimulus  of  the  external  air  fails  to  excite  any  attempt  to  breathe, 
or  calls  forth  only  feeble  gasps. 

Prolonged  pressure  on  the  foetal  head  in  difficult  labour  also 
eventually  causes  impairment,  and  at  last  destruction,  of  the 
irritability  of  the  respiratory  centre  in  the  medulla.  In  general, 
prolongation  of  the  pressure  appears  to  be  the  chief  element  in  the 
case.  But  it  is  possible  that  a  more  severe,  although  shorter, 
pressure  may  have  a  similar  effect.  This  may  be  the  reason  why  a 
frequent  and  early  use  of  forcej)s  appears,  from  reliable  statistics 
(see  pp.  630 — 633),  to  have  such  a  slight  influence  in  diminishing 


Injuries  and  Diseases  of  the  Foetus.     1087 

the  ratio  of  still-births,  and  one  so  much  less  than  has  been 
imagined  by  various  modern  authors.  Pressure  on  the  foetal  head 
may  produce  its  bad  effects  by  interfering  with  the  cerebral  circula- 
tion, by  direct  injury  to  the  brain,  or  by  causing  haemorrhage  into 
or  beneath  the  membranes  or  more  rarely  into  the  brain  substance, 
or  into  the  ventricles. 

In  many  cases  the  haemorrhage  is  set  up  by  tearing  of  the  venous 
sinuses,  the  result  of  the  compression  and  consequent  overlapping 
of  the  bones  of  the  vault  of  the  skull.  In  head-last  deliveries, 
when  the  medulla  oblongata  is  exposed  to  injury,  as  by  excessive 
traction  on  the  neck,  the  respiratory  centre,  or  its  connections  with 
the  nerves,  may  be  altogether  destroyed. 

Symptoms  and  Diagnosis.— Before  delivery,  if  the  fcetal  heart 
or  pulsation  of  the  funis  is  found  to  be  becoming  generally  slower 
and  more  feeble,  it  is  a  sign  of  impending  asphyxia.  An  especially 
loud  funic  soufSe  and  one  increasing  in  intensity  is  of  some  value 
as  a  sign  of  impending  asphyxia.  Temporary  retardation  of  the 
heart  is  generally  a  sign  of  temporary  pressure  on  the  funis,  but  in 
some  cases  danger  to  the  foetus  is  indicated  by  a  marked  increase  in 
the  heart  rate  or  by  irregularity  in  its  force  or  rhythm  rather  than 
a  slowing.  In  head-last  deliveries  asphyxia  is  indicated  by  attempted 
inspirations,  or  convulsive  movements  of  the  limbs,  and  the  escape 
of  meconium  in  other  than  breech  presentations  is  also  an 
indication. 

Asphyxia  Livida. — After  delivery,  the  symptoms  vary  according 
to  the  degree  of  the  asphyxia.  In  mild  cases,  the  appearance  of  the 
child  is  generally  livid  and  cyanotic,  especially  that  of  the  head,  if 
there  has  been  pressure  on  the  neck.  The  skin  is  dusky  red  and 
the  cutaneous  vessels  turgid.  The  muscle  tone  is  not  lost  and  the 
pharyngeal  and  cutaneous  reflexes  are  present.  The  heart's  action 
is  slow  but  well  marked,  and  pulsation  can  be  felt  in  the  funis. 
There  may  be  spontaneous  attempts  at  breathing.  These  generally 
take  the  form  of  deep  inspiratory  gasps,  due  to  contraction  of  the 
diaphragm,  which  have  more  effect  in  sucking  in  the  ribs  than  in 
drawing  in  air,  owing  to  the  obstruction  produced  by  the  fluid  which 
has  been  drawn  into  the  air-passages.  They  are  accompanied  by 
facial  contortion.  If  breathing  becomes  established,  naturally  or 
after  the  use  of  artificial  means,  rapid  and  very  shallow  diaphragm- 
atic breathing  generally  Ijecomes  continuous  between  the  deep 
gasps,  some  time  before  the  gasps  themselves  cease,  or  the  child 
gains  vigour  ejiougli  to  cry. 

If  any  air  is  inspired,    the  short  inspiration    is    followed  by   a 


io88  The  Practice  of   Midwifery. 

j)rolonged  expiration,  the  bronchi  being  obstructed  by  the  fluid 
which  has  been  drawn  in. 

Asphyxia  Pallida  or  Syncopal  Asphyxia. — In  the  graver  form  of 
asphyxia  the  skin  is  pale  and  white  instead  of  livid,  and  its 
sensibility  is  lost.  The  muscles  of  the  body  as  a  whole  have  lost 
their  tone  entirely  and  the  reflexes  are  generally  absent. 

The  child  after  birth  lies  limp  with  its  limbs  flaccid  and  the 
sjDhincters  are  relaxed.  There  is  as  a  rule  no  spontaneous  attempt 
at  breathing,  unless  artificial  means  are  used.  No  pulsation  is  felt 
in  the  funis,  the  vessels  of  which  are  collapsed,  and  the  heart's 
action  may  be  very  feeble  and  irregular  and  occurring  only  at  long 
intervals.  In  some  cases  the  heart's  rate  may  be  somewhat 
increased,  and  this  is  usually  a  sign  of  good  prognostic  omen. 
The  pulsation  of  the  heart  is  always  visible  while  any  pulsation 
continues,  and  should  be  looked  for,  not  listened  for.  This  form 
of  asphyxia  is  sj^ecially  likely  to  arise  from  prolonged  j)ressure  on 
the  head. 


Prognosis. — While  there  is  any  action  of  the  heart,  however 
slow  and  feeble,  there  is  always  hope  that  the  child  may  be 
resuscitated.  If  the  heart  has  ceased  beating,  it  is  useless  to 
attempt  any  treatment.  If  the  child  makes  any  spontaneous 
gasp,  either  shortly  after  delivery  or  while  artificial  respiration  is 
being  carried  out,  it  is  almost  certain  that  treatment  will  be 
successful  in  reviving  it,  if  persevered  with  long  enough.  There 
may,  however,  be  exceptional  cases,  as  when  the  larynx  has  been 
injured  by  unskilful  attempts  at  jaw-traction,  or  by  compression 
with  the  forcei)s  in  cases  of  face  or  brow  presentation.  If  there 
is  no  spontaneous  attempt  at  inspiration,  it  may  haj)j)en  that, 
although  the  heart's  action  may  be  maintained  for  an  hour  or 
more,  and  even  improved,  by  artificial  respiration,  yet  the  child 
cannot  be  induced  to  breathe.  In  such  cases  the  respiratory  centre 
has  probably  undergone  irrej)arable  injury.  In  some  instances, 
although  breathing  is  established,  and  the  child  may  even  cry,  yet 
it  remains  feeble,  and  dies  within  a  few  days.  In  such  cases  the 
condition  called  atelectasis  imlmonum  is  often  found  post  mortem. 
The  lungs  are  shown  to  have  been  only  imperfectly  expanded,  and 
a  considerable  proportion  of  them  still  remains  solid  and  airless. 
This  is  especially  likely  to  be  the  case  where  the  child  is  feeble 
or  premature.  With  feeble  and  premature  children  the  same 
condition  of  atelectasis  may  be  found,  if  the  child  dies  within  a 
few  days,  even  if    it  has  breathed  spontaneously  from  the   first. 


Injuries  and  Diseases  of  the  Foetus.      1089 

A  vigorous  cry  is  the  most  effectual  means  of  fully  expanding  the 
lungs. 

Treatment. — In  considering  the  treatment  of  cases  of  asphyxia 
neonatorum  we  must  remember  that  while  in  cases  of  asphyxia 
livida  the  reflex  excitability  of  the  respiratory  centre  is  still  present 
and  can  be  roused  into  activity  by  appropriate  reflex  stimuli,  in  the 
more  severe  form  of  asphyxia  pallida  the  excitability  of  the 
respiratory  centre  in  the  medulla  is  not  only  entirely  wanting,  but 
there  is  present  in  addition  a  considerable  degree  of  heart  failure 
and  a  condition  closely  resembling  that  of  shock. 

In  the  first  class  of  case  therefore,  our  main  endeavours  must 
be  directed  towards  exciting  the  respiratory  centre  to  action  by 
appropriate  stimuli,  while  in  the  second  or  more  severe  form  of 
asphyxia  pallida  our  endeavours  should  be  directed  towards 
restoring  the  excitability  of  the  centre,  and  this  can  best  be  done 
by  strengthening  the  heart's  action,  and  improving  the  condition 
of  the  foetal  blood. 

The  most  certain  method  is  the  j)erformance  of  artificial  respira- 
tion, which  oxygenates  the  blood,  promotes  the  cerebral  and  pulmo- 
nary circulations,  and  strengthens  the  heart's  action. 

Asphyxia  Livida. — If  the  child  does  not  breathe  freely  and 
cry  immediately  after  delivery,  the  first  thing  is  to  clear  away, 
as  far  as  possible,  any  inspired  mucus  which  may  be  obstructing 
the  air -passages.  The  child  should  be  turned  for  a  moment 
with  its  face  downward,  or  better  inverted,  and  the  back  of  the 
mouth  wij)ed  out  with  a  clean  napkin.  The  next  effort  should 
be  to  stimulate  respiration  by  reflex  stimulus.  This  may  be  done 
by  blowing  upon  the  child's  face  ;  if  this  fails,  by  flapping  its 
buttocks,  back,  or  chest  with  a  towel  wetted  in  cold  water,  or  by 
rubbing  its  skin  vigorously.  An  effectual  j)lan  is  to  have  two 
basins,  one  filled  with  hot,  the  other  with  cold  water,  and  to  dip 
the  child  for  a  moment  into  each  alternately,  repeating  this  several 
times.  Artificial  respiration  may  be  performed,  if  necessary,  while 
the  basins  are  being  prepared. 

If  the  child  does  not  respond  to  the  first  attempts  to  excite 
respiration,  such  as  flapping  it  with  a  towel,  the  funis  should  be 
tied  in  two  places  and  divided,  in  order  to  allow  the  means  for 
resuscitation  to  be  carried  out  more  readily.  If,  however,  pulsa- 
tion can  be  felt  in  the  funis,  as  will  be  the  case  only  in  the  milder 
forms  of  asphyxia,  artificial  respiration  may  be  tried  for  a  few 
minutes  before  the  child  is  separated.  It  is  generally  advised  that, 
if  the  child  appears  cyanotic,  a  little  blood  should  be  allowed  to 

M.  61) 


1090  The  Practice  of   Midwifery. 

escape  from  the  fcetal  end  of  the  cord,  before  the  ligature  is 
tightened.  This  does  not  appear  to  be  good  practice.  The 
cyanotic  form  of  asphyxia  is  not  the  most  serious  (see  p.  1087), 
and  the  cyanosis  very  quickly  passes  off  if  the  child  can  be  induced 
to  breathe.  Moreover,  it  is  to  be  remembered  that  the  early  ligature 
of  the  funis,  which  is  inevitable  when  the  child  is  asphyxiated  and 
no  pulsation  can  be  felt  in  the  funis,  is  itself  equivalent  to  bleeding 
the  child  to  a  considerable  extent.  To  allow  any  further  loss  of 
blood  appears,  therefore,  undesirable,  since  a  child  asphyxiated  at 
birth  sometimes  dies  within  a  few  days  from  feebleness  and 
atelectasis  pulmonum. 

If  response  does  not  soon  take  place  to  reflex  stimulus,  artificial 
respiration  should  be  performed  by  one  or  other  of  the  methods  to  be 
described,  or  rhythmical  traction  exerted  upon  the  tongue  according 
to  Laborde's  method.  This  has  the  advantage  that  it  can  be 
performed  without  the  aid  of  an  assistant  and  while  the  child  is 
immersed  in  a  hot  bath. 

Asphyxia  Pallida. — In  this  form  of  asphyxia  no  time  should  be 
lost  in  attempts  to  reflexly  excite  the  respiratory  centre,  but  after 
the  mouth  and  throat  have  been  cleared  of  all  mucus  artificial 
respiration  should  at  once  be  resorted  to.  At  the  same  time  means 
should  be  taken  to  strengthen  the  heart's  action.  This  can  be 
done  by  the  application  of  a  hot  sponge  to  the  cardiac  area  or  by 
immersing  the  child  in  a  hot  bath. 

While  artificial  respiration  is  being  carried  out  brandy  may  be 
rubbed  on  to  the  gums  or  over  the  precordial  area,  and  in  the 
worst  cases  a  hyi^odermic  injection  of  strychnine  l/2-300th  grain 
may  be  given.  In  view  of  the  condition  of  shock  which  is  present 
in  these  cases  a  cold  bath  should  not  be  employed,  nor  should  cold 
water  be  applied  to  the  skin. 

Another  method  that  may  be  resorted  to  is  artificial  inflation  of 
the  lungs. 

Ahlfeld  recommends  that  the  child  should  simply  be  placed  in 
a  hot  bath,  without  any  artificial  respiration.  If  no  spontaneous 
attemf)ts  at  respiration  aj)pear,  it  is  to  be  taken  out,  dried,  and  the 
skin  vigorously  rubbed  with  a  cloth. 

Artificial  Resjnration. — The  most  effectual  method  is  a  slight 
modification  of  that  of  Silvester.  To  carry  it  out  to  perfection  an 
assistant  is  required  to  fix  the  legs  of  the  child.  As  the  nurse  will 
generally  be  wanted,  to  keep  her  hand  upon  the  uterus  while  the 
physician  is  attending  to  the  child,  some  other  person  should,  if 
possible,  be  called  into  the  room  to  assist.  The  child  is  placed  on 
its  back,  the  head  supported,  but  moderately  extended,  so  that 


Injuries  and  Diseases  of  the  Foetus.      1091 

the  chin  is  not  pressed  upon  the  sternum,  the  thorax  being  slightly 
raised  by  a  napkin  placed  underneath  :  the  assistant  holds  the 
feet  firmly  in  a  napkin.  The  physician  stands  behind  the  child's 
head. 

To  imitate  inspiration,  he  grasps  the  arms  near  the  elbows, 
raises  them  from  the  sides  and  brings  them  near  together  above 
the  head,  at  the  same  time  making  gentle  traction  upwards.  It 
is  in  order  to  make  counter-traction  at  this  time  by  holding  the 
feet  that  the  assistant  is  required.  During  this  movement  the 
arms  should  be  somewhat  everted,  so  as  to  put  the  pectoralis 
major  more  upon  the  stretch.  This  movement  very  effectually 
expands  the  ribs.  The  effect  is  indeed  expended,  in  the  new-born 
infant,  more  in  sucking  in  the  abdomen,  through  the  medium 
of  the  diaphragm,  than  in  drawing  in  air.  But  by  repetition 
of  the  movement  more  and  more  air  gradually  gains  access  to 
the  lungs. 

To  imitate  expiration,  the  elbows  are  brought  down  and  j^ressed 
against  the  sides,  and  the  arms  somewhat  inverted,  so  as  to  bring 
the  fore-arms  across  the  chest.  By  means  of  the  fore-arms  and 
the  operator's  hands  pressure  is  made  upon  the  chest  and  abdomen, 
as  well  as  upon  the  sides,  so  as  to  squeeze  out  any  air  that  may 
have  been  inspired,  and,  with  it,  some  of  the  fluid  which  has 
entered  the  air-passages.  The  movements  should  not  be  made 
too  rapidly.  Twenty  times  in  the  minute  are  quite  sufficient. 
After  a  few  movements  the  back  of  the  mouth  may  again  be 
wiped  clear  of  any  mucus  or  liquor  amnii  which  may  have  been 
expressed.  If  the  air  does  not  aj)pear  to  enter  the  chest  the  child 
may  be  held  up  for  a  few  moments  by  the  feet,  head  downward, 
and  the  chest  compressed,  to  aid  the  evacuation  of  fluid  from  the 
bronchi.  If  any  attempt  at  spontaneous  inspiration  is  made, 
great  care  should  be  taken  so  to  time  the  movements  as  not  to 
counteract  but  to  aid  it ;  for  the  contraction  of  the  diaphragm  is 
of  more  avail  than  the  artificial  movements  in  drawing  in  air, 
especially  if  it  occurs  while  the  ribs  are  expanded  by  means  of 
the  arms ;  and  if  once  the  lungs  have  become  partially  aerated, 
the  artificial  resi)iralion  becomes  much  more  efficacious.  When 
the  attempts  at  breathing  become  more  frequent,  recourse  may  be 
had  again  to  the  plan  of  reflex  stimulation.  As  soon  as  regular 
breathing,  however  sli  allow,  begins  to  intervene  between  the 
spasmodic  gasps,  the  artificial  respiration  may  be  discontinued  in 
confidence  that  the  natural  breathing  will  steadily  improve. 

The  efficacy  of  this  method  is  shown,  not  only  by  the  frequency 
with  which  children  are  revived  by  it,  and  by  experiments  upon 

G9— 2 


1092 


The  Practice  of   Midwifery. 


still-born  children/  but  by  the  fact  that  the  heart's  action  can 
often  be  by  this  means  maintained  for  a  long  time,  and  even 
quickened,  and  the  colour  of  the  skin  improved,  even  though  the 
irritability  of  the  respiratory  centre  is  lost  past  restoration.  As  a 
rule,  however,  the  improvement  of  the  heart's  action  is  a  hopeful 
sign,  though  not  so  significant  as  the  commencement  of  spontaneous 
gasps. 

In  the  absence  of  an  assistaijt,  this  method  cannot  be  carried 
out  to  the  full  extent.  The  elbows  may  be  simply  raised  above  the 
head,  but  scarcely  any  upward  traction  upon  them  while  in  this 
position  can  be  made.  The  absence  of  such  traction  seriously 
diminishes  the  efficacy  as  regards  the  expansion  of  the  ribs.     The 


Fig.  502.— Schultiie's 
method.  Position 
of  expiration. 


FIG.  503.— Schnltze's 
method.  Position 
of  inspiration. 


movements  may   therefore  be   made   more   quickly,    in   order   to 
compensate  in  some  measure  for  this. 

Sclmltzes  Method. — The  oj)erator  stands  with  somewhat  separated 
legs,  and  bends  slightly  forward.  He  grasps  the  child  as  shown  in 
Fig.  502,  the  thumbs  lying  on  the  anterior  wall  of  the  thorax,  the 
index  fingers  extending  from  behind  the  shoulders  into  the  axillae, 
the  other  three  fingers  of  each  hand  lying  on  the  posterior  wall  of 
the  thorax.  He  holds  the  child  at  arm's  length,  hanging  perpendicu- 
larly. He  swings  the  child  upward  from  this  hanging  position  at 
arm's  length  to  a  level  somewhat  above  his  head  into  the  j)osition 
shown  in  Fig.  502.  The  raising  of  the  child  as  far  as  the  hori- 
zontal should  be  effected  by  a  powerful  swing  of  the  arms,  but 


1  It  has  been  shown  by  Champneys  that  in  such  expcsriraents  Silvester's  method  is 
found  to  be  more  efficacious  for  introduction  of  air  than  others  which  have  been 
employed,  such  as  those  of  Marshall  Hall,  Howard,  Schultze,  etc.,  especially  if  the 
arras  are  everted  during  the  movement  for  inspiration  (Med.-Chir.  Trans.,  Vol.  LXIV.). 


Injuries  and  Diseases  of  the  Foetus.      1093 

from  that  point  the  arms  should  be  raised  more  and  more  slowly, 
so  that  the  pelvic  end  of  the  child  falls  gradually  over.  By  this 
falling  of  the  child's  pelvis  over  the  abdomen,  considerable  pressure 
is  exercised  on  the  thoracic  viscera,  and  inspired  fluids  often  pour 
from  the  mouth  and  nose.  The  operator  then  again  lowers  his 
arms  so  as  to  swing  the  child  down  again  between  his  separated 
legs  into  the  position  shown  in  Fig.  503.  The  child's  body  is 
thereby  extended  with  some  impetus,  and  effects  ins]3iration  by 
causing  descent  of  the  diaphragm.  After  a  pause  of  a  few  seconds 
the  child  is  again  swung  upwards  into  the  previous  position,  and 
expiration  is  thus  effected.  The  proceeding  is  rej^eated  eight  or 
ten  times  a  minute.  This  method  has  the  advantage  of  requiring 
no  assistant,  and  the  inverted  position  aids  the  escape  of  inspired 
fluids ;  but  the  inspiratory  movement  does  not  a23pear  to  be  so 
effective  as  in  Silvester's  method.  It  presents  the  further  disad- 
vantages that  a  considerable  amount  of  chilling  of  the  child's  body 
is  produced,  and  it  cannot  be  combined  with  the  use  of  the  hot 
bath — a  most  important  factor  in  the  restoration  of  cases  of 
asphyxia  pallida. 

P rochoivnick' s  Method. — The  child  is  held  up  by  the  feet,  head 
downward,  by  an  assistant,  the  arms  extended  by  the  side  of  the 
head.  This  is  the  position  for  inspiration.  Expiration  is  effected 
by  grasping  the  chest  with  both  hands,  the  fingers  over  the 
sternum,  and  compressing  it. 

Both  this  method  and  that  of  Schaefer,^  although  physiologically 
the  most  correct,  since  they  tend  to  initiate  insj)iratory  movements 
by  emptying  the  lungs,  a  more  powerful  stimulus  to  the  respiratory 
centre  than  that  produced  by  filling  the  lungs,  are  obviously  of 
little  value  in  the  asphyxiated  new-born  child,  in  whom  the  lungs 
are  generally  quite  unexpanded, 

Lahorde's  Method  of  Tongue  Traction. — The  tongue  of  the  child 
is  seized  in  a  napkin,  and  rhythmical  tractions  are  made  upon  it 
at  the  rate  of  twenty  to  thirty  to  the  minute.  This  method  excites 
respiratory  movement  by  reflex  stimuli  conveyed  to  the  respiratory 
centre  through  the  branches  of  the  lingual,  glosso-jiharyngeal  and 
superior  laryngeal  nerves.  No  direct  means  of  artificial  respiration 
is  emj)loyed. 

Tracheal  Insufjiation. — The  plan  of  direct  insufflation  of  the 
lungs  through   the   trachea  has  been  more  used  abroad  than  in 

^  Schaefer's  method  is  of  the  g7'catest  value  in  the  resuscitation  oi:  the  apparently 
drowncfl,  and  consists  in  compression  of  the  chest  to  [)roduce  expiration  (the  subject 
Vjeing  plMC'-d  in  the  prone  position),  and  allDwinj^  the  ex|)ansion  of  the  chest  walls  to 
prfKliwje  the  movement  of  inspiration. 


I094  The  Practice  of   Midwifery. 

this  country.  It  has  the  disadvantage  that  ruiDture  of  the  air- 
cells  and  emphysema  may  be  caused  by  the  force  used.  It  may, 
however,  be  tried  if  other  means  fail.  My  own  experience  has 
not  been  that  it  succeeds  when  Silvester's  method  does  not.  In 
France,  insufflators  made  for  the  purpose  are  used,  having  a  curve 
corresponding  to  the  child's  mouth,  and  a  conical  extremity 
to  fit  closely  into  the  larynx.  With  these,  an  indiarubber  ball 
may  be  used  for  the  insufflation.  In  the  absence  of  an  insufflator, 
a  gum-elastic  catheter.  No.  6,  may  be  used.  This  is  guided  by  the 
tip  of  the  finger  behind  the  epiglottis  and  into  the  trachea,  care 
being  taken  not  to  pass  it  into  the  cesophagus.  First  suction 
should  be  made  to  remove  some  of  the  inspired  fluid,  if  possible, 
from  the  air-passages.  With  an  insufflator,  the  suction  is  made 
by  first  emj)tying  the  indiarubber  ball  and  then  allowing  it  to 
refill  by  its  own  elasticity.  The  fluid  in  the  trachea  having  been 
sucked  out,  the  operator  takes  one  or  two  deep  breaths,  to  remove 
as  much  carbonic  acid  as  possible  from  his  lungs,  and  then  blows 
gently  into  the  tube.  The  chest  is  then  compressed,  to  imitate 
expiration,  and  the  same  process  is  continued.  Faradisation  of 
the  phrenic  nerves  has  sometimes  proved  effectual,  and  may  be 
tried  as  a  last  resort  if  a  Faradic  battery  is  at  hand,  but  artificial 
respiration  is  jJreferable. 

The  direct  insufflation  of  oxygen  into  the  lungs  may  be  tried  if 
it  is  at  hand,  and  the  intravenous  injection,  through  the  umbilical 
vein,  of  saline  fluid  has  been  employed  with  benefit  in  cases  of 
marked  anaemia  of  the  foetus. 

Mastitis  Neonatorum. — In  the  majority  of  young  infants,  both 
male  and  female,  slight  swelling  of  the  mammary  glands  occurs 
about  the  third  or  fourth  day  after  birth,  and  continues  until  the 
eighth  to  tenth  day.  In  some  cases  the  breasts  swell  up  to  the 
size'  of  a  walnut,  and  usually  they  secrete  small  quantities  of  a 
fluid,  the  Hexenmilch  of  the  Germans,  indistinguishable  both  in 
appearance  and  on  chemical  analysis  from  ordinary  human  milk. 

If  the  breasts  are  manipulated  by  mothers  or  nurses  in  an 
attempt  to  break  the  so-called  nipple  strings,  or  even  without  any 
such  cause,  slight  mastitis  not  infrequently  follows. 

This  usually  runs  a  subacute  course  and  undergoes  resolution, 
but  in  a  small  percentage  of  the  cases  suppuration  occurs,  and  an 
abscess  forms.  No  doubt  such  an  attack  of  inflammation  may  be 
followed  in  after-life  by  atroj)hy  of  the  breast  tissue  and  inability 
to  suckle. 

It  is  of  the  utmost  importance  that  no  attempt  should  be  made 
to  disperse  the  swelling,  as  is  often  done  by  ignorant  nurses.      In 


Injuries  and  Diseases  of  the  Foetus.      1095 

slight  cases  it  is  sufficient  to  keep  the  swollen  glands  protected 
from  rubbing.  In  more  severe  cases  a  hot  fomentation  may  be 
a]3plied,  while  if  an  abscess  forms  it  should  be  opened  by  a  small 
incision. 

Ophthalmia  Neonatorum. — Inflammation  of  the  eyes  of  a  new-born 
child  is  a  disease  which  has  been  known  for  many  years,  but  it  is 
only  since  the  discovery  of  the  gonococcus  by  Neisser  that  the 
close  relationship  between  this  disease  and  gonorrhoea  in  the  mother 
has  been  recognised. 

In  about  75  per  cent,  of  the  cases  the  gonococcus  is  found  in 
the  discharge,  but  other  organisms,  such  as  the  staphylococcus, 
Loffler's  dij^htheria  bacillus,  the  pneumococcus,  and  the  colon 
bacillus,  may  be  present  and  set  up  the  inflammation. 

In  most  instances  infection  occurs  just  after  birth  by  the  trans- 
ference of  the  infectious  matter  from  the  eyelids  to  the  conjunctiva 
when  the  infant  opens  its  eyes. 

In  some  cases  no  doubt  infection  occurs  intra  ijartum,  and  in  a 
few  instances  children  are  rej)orted  to  have  been  born  with 
ophthalmia,  indicating  that  the  infection  had  occurred  in  utero. 
There  would  appear  to  be  some  casual  relationship  between 
premature  rupture  of  the  membranes  and  this  occurrence,  and  in 
face  presentations,  for  example,  the  child  may,  and  no  doubt  does, 
open  its  eyes  before  birth.  In  cases  of  late  infection  occurring 
some  days  after  birth  the  introduction  of  lochial  discharge  or  pus 
into  the  eyes  by  the  fingers  of  the  mother  or  the  nurse  or  the  use 
of  dirty  towels  may  be  the  cause,  or  the  entrance  of  dust  and  dirt 
containing  one  or  other  of  the  organisms  found.  The  importance 
of  the  condition  will  be  recognised  when  it  is  remembered  that  in 
the  year  1876  30  per  cent,  of  the  cases  of  blindness  in  blind 
asylums  were  due  to  this  cause,  and  as  recently  as  1895  some 
19  per  cent.,  if  late  infections  are  included. 

If  the  infection  takes  place  during  or  immediately  after  birth  the 
disease  begins  from  the  second  to  the  sixth  day.  If  the  first 
symptoms  appear  later  than  the  sixth  day  it  may  be  concluded  that 
the  infection  has  been  derived  from  the  introduction  of  septic 
matter  into  the  eyes  by  the  mother  or  nurse.  In  the  new-born 
infant  both  eyes  are  commonly  affected. 

In  mild  cases  the  palpebral  conjunctiva  is  alone  involved,  and 
there  is  merely  a  small  amount  of  sero-purulent  discharge.  In 
more  severe  cases  there  is  swelling  and  injection  of  both  bulbar  and 
palpebral  conjunctivas  with  chemosis,  and  swelling  of  the  eyelids, 
and  the  early  serous  discharge  changes  into  the  characteristic 
purulent  form.     In  a  severe  attack  after  a  period  usually  of  some 


1096  The  Practice  of   Midwifery. 

two  to  six  or  eight  weeks,  the  swelling  and  chemosis  of  the  eyelids 
and  conjunctivae  gradually  diminishes,  and  the  discharge  lessens. 

The  main  danger  of  the  condition  is  the  involvement  of  the 
cornea.  This  may  lead  to  simple  losses  of  the  surface  epithelium, 
marked  infiltration  of  the  cornea,  or  the  formation  of  ulcers  with, 
in  some  cases,  the  occurrence  of  perforation  of  the  cornea. 

The  prevention  of  ophthalmia  neonatorum  is  of  the  utmost 
possible  importance,  especially  in  lying-in  hospitals.  As  has  been 
already  mentioned  (see  p.  306),  immediately  after  the  birth  of  the 
head  the  eyes  and  their  neighbourhood  should  be  wiped  clean  from 
mucus  or  blood  with  a  piece  of  absorbent  wool  soaked  in  a  saturated 
solution  of  boracic  acid  lotion  or  in  a  1  in  4,000  perchloride  or 
biniodide  of  mercury  solution.  If  any  purulent  vaginal  discharge 
has  been  noticed  or  if  there  is  any  reason  to  suspect  the  presence 
of  gonorrhoea  in  the  mother,  a  few  drops  of  one  or  the  other  of  the 
following  solutions  should  be  dropped  into  the  eyes :  1  in  2,000 
perchloride  of  mercury,  a  2  per  cent,  solution  of  silver  nitrate,  or  a 
solution  of  argyrol  25  to  60  per  cent.,  or  of  protargol  10  to  20  per  cent. 
The  irritation  set  up  by  the  use  of  the  silver  nitrate  solution  is  said 
to  be  prevented  by  the  use  of  the  two  latter,  and  the  disadvantage 
of  all  these  silver  solutions  of  undergoing  decomposition  and  change 
if  kept  for  any  length  of  time  is  avoided  by  the  employment  of  a 
5  per  cent,  solution  of  sophol.-^ 

The  local  treatment  of  the  condition  consists  in  the  washing  or 
irrigation  of  the  eye  with  1  in  10,000  permanganate  of  potash 
solution  or  1  in  5,000  perchloride  of  mercury  solution.  Iced 
compresses  may  also  be  applied,  and  the  chemosis,  if  excessive, 
snij)ped  with  scissors.  Later  in  the  disease,  when  the  conjunctiva 
has  become  velvety  and  the  discharge  purulent,  the  best  aj)plication 
is  a  solution  of  silver  nitrate  15  to  20  grains  to  the  ounce,  to  be 
painted  on  the  conjunctiva  of  the  everted  lids  and  neutralised  with 
a  solution  of  common  salt.  This  may  be  rej^eated  once  every 
twenty-four  hours.  In  the  intervals  the  eye  should  be  frequently 
washed  with  a  4  per  cent,  solution  of  boric  acid  or  a  1  in  5,000 
solution  of  perchloride  of  mercury  and  boric  acid  ointment  apj)lied 
to  the  margins  of  the  lids.  Any  sign  of  congestion  in  the  other 
eye  should  be  treated  by  the  immediate  application  of  a  2  per  cent, 
solution  of  silver  nitrate.  The  involvement  of  the  cornea  necessi- 
tates the  more  vigorous  use  of  these  remedies,  with  the  instillation 
of  atropine. 

Thrush  is  a  parasitic  disease  due  to  the  invasion  of  the  mucous 
membrane  of  the  mouth  by  the  bud  fungus  known  as  the  Saccharo- 

•  Sophol  contains  formaldehyde,  nucleinic  acid,  and  22  per  cent,  of  silver. 


Injuries  and  Diseases  of  the  Foetus.      1097 

myces  albicans.  It  is  essentially  a  disease  of  new-born  children. 
It  may,  however,  occur  at  other  periods  of  life,  but  as  a  rule  only  in 
the  very  old  or  in  patients  debilitated  by  an  acute  illness. 

Besides  the  buccal  mucous  membrane  it  may  invade  the  intestinal 
mucosa,  and  may  occur  on  the  mucous  membrane  of  the  vagina ;  in 
the  latter  position  it  is  possible  that  it  may  infect  the  infant  during 
its  birth. 

The  infection  is  no  doubt  at  times  derived  from  the  air,  but  more 
commonly  from  dirty  teats  or  feeding  bottles,  as  it  is  mainly  a  dirt 
disease.  In  lying-in  hospitals  it  spreads  occasionally  from  one 
child  to  another  and  exhibits  contagious  properties. 

Thrush  appears  first  as  snow-white  masses  of  minute  size  on  the 
mucous  membrane  of  the  mouth,  which  coalesce  with  one  another, 
and  which,  when  scraped  off  and  examined  under  the  microscope, 
exhibit  the  typical  appearances  of  the  fungus,  viz.,  branching  and 
anastomosing  mycelial  threads  and  spores. 

By  scrupulous  cleanliness  the  occurrence  of  thrush  can  be  entirely 
prevented,  and  its  treatment  is  therefore  mainly  prophylactic.  The 
nipple  and  the  child's  mouth  after  each  nursing  should  be  carefully 
wiped  with  a  lotion  of  equal  parts  of  a  saturated  solution  of  boric 
acid  and  hot  water,  and  the  nipple  should  then  be  carefully  dried. 

If  thrush  occurs  a  small  dose  of  castor  oil  should  be  adminis- 
tered at  once  and  some  preparation  of  boric  acid  applied  to  the 
mouth.  It  may  be  wiped  out  with  a  clean  piece  of  linen  soaked  in 
glycerine  of  borax,  or  the  plan  advocated  by  Escherich^  may  be 
adopted.  A  small  mass  of  boric  acid  powder  is  wrapped  in  a  little 
wool,  enclosed  in  a  layer  of  fine  linen,  and  soaked  in  a  solution  of 
syrup.  This  is  then  given  to  the  child  to  suck,  and  in  this  manner 
a  sufficient  amount  of  boric  acid  is  absorbed  to  act  as  an  excellent 
mouth  and  intestinal  antiseptic. 

The  mouth  should  be  repeatedly  cleaned,  and  this  may  be  most 
effectually  done  with  a  5  per  cent,  solution  of  bicarbonate  of  soda. 

In  very  rare  instances  thrush  spreads  from  the  buccal  cavity  to 
the  intestinal  canal,  and  may  lead  to  ulceration  of  the  small 
intestine  and  death  from  perforation  or  septic  poisoning.^ 

Tightness  of  Fkenum  Ling-uje. — In  some  cases  the  frenum 
lingua;  extends  too  forward  toward  the  tip  of  the  tongue,  so  as  to 
prevent  the  tongue  being  extruded,  and  the  child  is  then  said  to  be 
tongue-tied.  This  condition  may  make  it  impossible  to  suck ;  and, 
if  not  relieved,  may  afterwards  interfere  with  articulation. 

Treatment. — The  thin  part  of   the  frenum    should   be  snipped 

'  De  Forrest,  Amor.  Journ.  Obstet.,  January,  llilO,  p.  1()2. 

2  Mikulicz-Uaditzky  and  Kiinimel,  Die  Krankheiten  des  MundeSj  .Jena,  1 !)()!). 


1098  The  Practice  of   Midwifery. 

through   with    blunt-pointed    scissors,    care    being    taken   not   to 
endanger  the  hngual  artery. 

Tetanus  Neonatorum  is  of  particular  interest  to  English 
obstetricians  on  account  of  its  extreme  prevalence  until  recent 
years  in  the  island  of  St.  Kilda,  in  the  Hebrides.  It  is  identical 
with  tetanus  following  any  wound  or  operation,  and  is  only  peculiar 
in  that  the  usual  site  of  entrance  of  the  tetanus  bacillus  is  the 
umbilical  wound.  It  is  directly  associated  with  the  want  of  proper 
antiseptic  precautions  in  dressing  the  umbilicus,  and  since  the 
inhabitants  of  St.  Kilda  have  been  taught  the  importance  of  such 
antiseptic  dressings  the  disease,  which  at  one  time  accounted  for  the 
death  of  nearly  80  per  cent,  of  the  new-born  babies  in  tbat  locality, 
has  practically  disappeared.  It  is  still  prevalent  in  some  of  the 
West  Indian  islands,  and  is  responsible  for  a  large  number  of  deaths 
among  negro  infants.  It  is  reputed  to  have  followed  the  use  of 
impure  fuller's  earth,  and  has  been  met  with  as  a  result  of  the 
operation  of  circumcision.  The  onset  of  the  disease  may  be  on  the 
first  or  even  second  day  after  birth,  but  more  often  it  does  not 
commence  until  the  end  of  the  first  week  of  life. 

The  most  characteristic  feature  of  tetanus  neonatorum,  and  one 
which  generally  persists  during  the  whole  course  of  the  attack,  is 
the  spasms  of  the  muscles  of  the  jaw.  Later  the  muscles  of  the 
trunk  and  those  of  the  limbs  become  affected,  and  opisthotonos  is 
often  present. 

The  diagnosis  has  to  be  made  from  pseudo-tetanus,  and  the  main 
distinction  lies  in  the  occurrence  of  clonic  spasms,  es^jecially  in  the 
eye  muscles,  in  the  latter,  and  the  ultimate  development  of  paralysis. 
The  i^rognosis  is  exceedingly  bad,  death  usually  following,  in  some 
93  to  95  per  cent,  of  the  cases,  about  the  eighth  day  of  the  disease. 

The  treatment  consists  in  the  administration  of  tetanus  antitoxin, 
although  unless  this  is  begun  at  a  very  early  stage  in  the  course  of 
the  disease  the  results  are  most  disa^Dpointing  (vide  p.  1047).  The 
muscular  spasms  are  best  relieved  by  chloral  or  the  inhalation  of 
chloroform. 

Icterus  Neonatorum. — Although  simple  or  idiopathic  icterus 
neonatorum  is  interesting  etiologically  (see  p.  400),  yet  clinically  it 
is  of  little  importance  and  usually  passes  off  within  the  first  week 
of  Hfe. 

The  other  forms  of  jaundice,  although  less  frequent,  are  of  equal 
interest  from  the  point  of  view  of  their  causation  and  of  far  greater 
importance  clinically  owing  to  the  heavy  foetal  mortality  with  which 
they  are  usually  associated. 


Injuries  and  Diseases  of  the  Foetus.     1099 

The  most  important  ^etiological  factors  in  these  forms  of  jaundice 
are  malformations  of  the  bile  ducts,  congenital  syphilis,  the  various 
forms  of  septic  infection  having  their  starting  point  in  the  umbilicus, 
certain  diseases  of  doubtful  nature  such  as  Buhl's  disease  and 
"Winckel's  disease,  and  occasional  attacks  of  jaundice  of  catarrhal 
origin. 

In  the  simple  jaundice  of  the  new-born  child  all  the  internal 
organs  show  a  yellow  tinge.  The  presence  of  bile  acids  and  bile 
pigment  in  the  pericardial  fluid  proves  that  the  yellow  colour  is 
really  due  to  bile,  and  that  most  cases  at  any  rate  are  not  simply 
haematogenous  in  origin.  Its  causation  is  no  doubt  associated  with 
the  important  changes  which  occur  at  birth  in  the  circulation  of 
the  new-born  infant.  An  extensive  destruction  of  red  blood 
corpuscles  occurs,  and  according  to  Abramov,  the  backward  pressure 
in  the  capillaries  of  the  liver  prevents  the  liver  cells  from  disposing 
of  the  bile  they  form,  which  therefore  passes  into  the  blood-vessels.^ 

The  proportion  of  infants  affected  is  very  high,  nearly  80  jDer 
cent,  according  to  some  authors.  The  characteristic  feature  of  this 
form  of  jaundice  is  the  fact  that  the  skin  is  mainly  affected.  The 
urine  and  faeces  are  normal ;  and  the  eyes  are  often  not  at  all  or  very 
little  discoloured,  and  these  facts  together  with  the  absence  of  any 
serious  symptoms  serve  to  distinguish  it  from  the  more  severe 
varieties. 

Icterus  from  Congenital  Obliteration  of  the  Bile  Ducts. — 
The  obliteration  may  affect  almost  any  part  of  the  ducts,  and  may 
involve  the  gall  bladder ;  the  liver  is  generally  in  a  condition  of 
biliary  cirrhosis,  is  enlarged  and  of  an  olive-green  colour.  There  is 
as  a  rule  a  good  deal  of  fibrous  thickening  round  the  obliterated 
structures.  According  to  Thomson  and  Milne,  the  pathology  of 
these  cases  is  as  follows  :  A  congenital  narrowing  of  the  bile  duct 
leads  to  the  stagnation  of  bile  in  the  liver  and  to  the  gradual 
accumulation  in  that  organ  of  the  toxic  products  of  metabolism. 
These  set  up  necrosis  of  the  liver  cells  and  resulting  cirrhosis,  so 
that  the  functions  of  the  liver  are  carried  out  inadequately,  and  the 
child  dies  of  toxic  poisoning,  as  evidenced  by  the  occurrence  of 
vomiting,  haemorrhages  and  convulsions. 

At  birth  the  child  is  often  of  normal  appearance,  but  within  a 
few  days,  occasionally  not  until  the  end  of  the  first  week,  well- 
marked  jaundice  sets  in,  which  becomes  more  and  more  marked  and 
remains  until  death.  The  urine  is  deeply  bile-stained,  and  the 
faeces  are  colourless.    Haemorrhage  from  the  navel  is  a  very  constant 

1  Thomson,  Clifford  Allbutt's  System  of  Medicine,  Vol.  IV.,  I't.  1,  p.  100  ;  Abramov, 
Vir(  li.  Archiv,  1905,  clxxxi.,  p.  201. 


iioo  The  Practice  of   Midwifery. 

and  fatal  symptom,  and  blood  may  be  vomited  or  passed  with 
tbe  motions.  The  result  is  always  a  fatal  one,  and  no  child  with 
this  complaint  has  ever  lived  eleven  months.^  Treatment  is  of  no 
avail. 

Septic  Infections  of  the  New-boen. 

Jaundice  of  Septic  Origin  may  have  its  starting  point  in  the 
umbilicus  or  in  the  intestine.  The  former  is  due  to  the  entrance 
of  pathogenic  organisms,  such  as  the  strei^tococcus,  by  the  umbilical 
vein,  and  the  latter  probably  to  the  bacillus  coli  from  the  bowel.  In 
the  first  the  main  synii^toms  are  jaundice,  haemorrhages  and  fever, 
and  in  the  second  there  is  jaundice,  marked  cyanosis,  and  diarrhoea. 
In  both  the  prognosis  is  bad  and  treatment  of  little  avail. 

Hcemoglohinuria  Neonatorum,  or  WinckeVs  Disease. — This,  too,  is 
no  doubt  of  septic  origin,  and  results  from  infection  with  an  organism 
so  far  not  identified.  The  children,  born  healthy,  become  affected 
two  or  three  days  after  birth,  and  die  often  within  thirty-six  hours 
of  the  onset  of  the  disease.  They  have  a  markedly  cyanotic  and 
jaundiced  tint,  the  urine  contains  a  large  amount  of  blood,  the 
stools  are  black-green  in  colour  and  the  pulse  rapid,  but  the 
temperature  normal.  Post-mortem  examination  shows  haemorrhages 
into  many  of  the  organs  of  the  body,  esj^ecially  into  the  convoluted 
tubules  of  the  kidneys,  which  also  contain  large  numbers  of 
organisms.  The  disease  may  occur  in  an  epidemic  form,  and  has  a 
high  mortality. 

BukVs  Disease,  or  Fatty  Degeneration  of  the  new-born,  is  also  with- 
out doubt  of  septic  origin.  It  is  characterised  by  increasing  cyanosis 
and  pathologically  by  parenchymatous  inflammation  and  fatty 
degeneration  of  many  of  the  organs  of  the  body  and  multij)le 
haemorrhages  in  various  parts  of  the  body,  such  as  the  pleura,  the 
pericardium,  the  lungs,  the  stomach,  and  the  intestine,  and  bleeding 
from  the  navel. 

The  children  are  often  still-born.  Those  that  live  present  a  blue 
colour,  which  becomes  tinged  with  yellow,  while  later  diarrhoea  sets 
in  with  the  passage  of  blood  and  often  haematemesis.  The  site  of 
entrance  of  the  poison  is  undetermined,  but  the  fact  that,  since 
antisei)tic  treatment  of  the  umbilical  cord  has  come  into  general 
use,  the  disease  has  practically  disappeared  from  lying-in  hospitals 
is  suggestive. 

Inflammation  and  Septic  Infection  of  the  Umbilicus  may  vary  from 
a  mere  local  inflammatory  process,  leading  to  the  development  of 

1  Thomson,  Clifford  Allbutt's  System  of  Medicine,  Vol.  IV.,  Ft.  1,  p.  108. 


Injuries  and  Diseases  of  the  Foetus,      iioi 

an  ulcer  or  a  little  granuloma  at  the  site  of  the  separated  cord, 
to  a  most  virulent  infection,  spreading  through  the  umbilical 
vessels  and  rapidly  ending  fatally. 

A  mild  local  infection  generally  is  evidenced  by  the  presence  of  a 
small  ulcer,  or  if  the  condition  persists  without  projDer  treatment 
a  little  granulomatous  polypus  may  form,  which  will  require 
treatment  with  solid  silver  nitrate.  In  other  cases  the  inflamma- 
tion spreads  to  the  surrounding  skin  or  cellular  tissue,  and  ery- 
sipelas may  occur,  starting  at  the  umbilicus.  In  a  few  instances 
there  may  be  no  signs  of  local  inflammation,  but  the  entrance  of 
septic  organisms  through  the  arteries  or  veins  is  evidenced  by  the 
occurrence  of  periarteritis  or  thrombo-phlebitis. 

Associated  often  with  these  conditions  is  haemorrhage  from  the 
umbilicus,  the  so-called  omphalorrhagia  neonatorum,  which  as  a 
rule  begins  insidiously  about  the  end  of  the  first  week  of  life,  and 
not  uncommonly  leads  to  a  fatal  termination  in  a  few  hours.  The 
disease  is  luckily  very  rare  (once  in  5,000  confinements),^  and 
appears  to  affect  males  rather  than  females.  On  inspection  the 
blood  does  not  come  from  any  single  vessel,  but  is  rather  a  general 
oozing  from  the  stump  of  the  umbilical  cord.  Its  cause  is  obscure, 
undoubtedly  in  many  cases  it  is  merely  a  symj)tom ;  thus  it  is  a 
common  accompaniment  of  all  forms  of  septic  infection  in  the  new- 
born, and  is  frequent  in  Buhl's  disease.  Hsemophilia  and  con- 
genital syphilis  are  said  to  be  setiological  factors,  but  probably  only 
when  associated  with  septic  processes.  The  condition  has  also 
been  ascribed  to  congenital  malformations  of  the  heart  and  blood- 
vessels. Ballantyne  points  out  that  it  may  occur  in  more  than  one 
member  of  a  family.^ 

The  treatment  consists  in  prolonged  digital  compression  of  the 
bleeding  area,  or  adrenalin,  calcium  chloride,  plaster  of  Paris,  or 
the  actual  cautery  may  be  applied  locally.  If  necessary  the  base 
of  the  bleeding  area  may  be  transfixed  with  a  hare-lip  j)in  and  a 
ligature  applied  around  it. 

The  prognosis  as  a  rule  is  very  bad,  the  mortality  amounting  to 
65  to  84  per  cent.,  and  many  cases  end  fatally  within  twenty-four 
hours. 

MelcBiia  Neonatorum. — Occasionally  in  these  cases  the  blood  is 
vomited,  but  more  commonly  it  is  passed  by  the  bowel  and  is  quite 
black  in  colour  and  intimately  mixed  with  the  motions.  The 
bleeding  most  commonly  begins  on  the  second  day  of  life,  but 
occasionally  later.     The  amount  varies  greatly  in  different  cases. 

'  Ribemont,  Des  Hcmorragics  chez  le  nouveau  Nd',  These,  Paris,  1880. 
2  Ballantyne,  Antenatal  Pathology,  "  The  Fujtus,"  1902,  p.  <)(>. 


II02  The  Practice  of   Midwifery. 

The  causation  of  this  condition  is  very  obscure,  but  most 
probably  it  is  a  manifestation  of  some  form  of  septic  infection  of 
the  new-born  child.  In  favour  of  this  view  is  the  fact  that  a  large 
number  of  different  organisms  have  been  cultivated  from  the  blood 
and  tissues. 

Cases  have  been  published  where  melfena  has  been  associated 
with  haemorrhages  into  the  cerebral  peduncles  and  the  fourth 
ventricle,  and  in  other  cases  various  local  morbid  conditions  have 
been  described. 

Landau  suggests  that  delayed  inspiration  in  feeble  children  leads 
to  clotting  of  the  blood  in  the  umbilical  vein,  and  that  from  this 
an  embolus  is  carried  to  one  of  the  vessels  of  the  stomach,  and 
ulceration  results.  Congenital  syphilis  or  congenital  debility  are 
other  supposed  cause  factors.  The  prognosis  is  always  grave, 
some  50  to  60  i^er  cent,  of  the  children  succumbing. 

In  a  case  of  this  kind  the  vitality  of  the  child  must  be  carefully 
guarded,  and  it  should  be  kept  warm,  if  possible,  in  an  incubator. 
Salt  solution  may  be  transfused  subcutaneously  or  slowly  injected 
into  the  rectum.  The  best  drug  to  give  is  adrenalin  chloride,  of 
which  a  half  to  one  minim  of  a  1  in  1,000  solution  may  be  given 
by  the  mouth  every  two  hours.  A  sterile  2  per  cent,  solution  of 
gelatin  may  be  injected  subcutaneously  in  doses  of  two  drachms. 
If  these  fail  ergot  may  be  tried. ^ 

The  child  should  not  be  allowed  to  suck,  but  should  be  fed  with 
a  spoon  or  dropper. 

1  Thomson,  ClifiEord  AUbutt's  System  of  Medicine,  1909,  Vol.  V.,  p.  876. 


Chapter  XLIII. 
DISEASES    OF   THE    BREASTS, 

Abnormalities  in  the  Quantity  of  Milk. — The  normal  amount 
of  milk  secreted  varies  within  wide  limits.  Temesvary/  in  a 
long  series  of  observations,  found  the  average  amount  from  one 
breast  to  be  two  ounces,  the  variations  being  from  one  to  two  and 
a  half  ounces.  At  the  end  of  the  first  week  the  total  amount 
secreted  in  twenty-four  hours  is  about  fourteen  ounces,  at  the  end 
of  the  first  month  about  two  pints,  while  at  the  end  of  the  seventh 
it  has  attained  its  maximum  of  about  three  pints,  and  after  this  it 
gradually  diminishes  again  in  quantity. 

Deficient  Secretion  of  Milk,  or  Agalactia. — In  the  absence  of 
any  febrile  disturbance,  a  deficient  secretion  of  milk  generally 
depends  upon  some  constitutional  state  not  to  be  remedied  by  drugs. 
It  is  met  with  more  especially  in  very  feeble  or  fat  women,  in 
elderly  primiparse,  and  after  a  premature  confinement.  It  is 
especially  common  when  the  mother  has  to  return  to  hard  work 
soon  after  her  confinement,  as  so  often  happens  among  the  women 
of  the  poorer  classes.  So  long  as  there  is  hope  that  the  mother  will 
be  able  to  suckle,  even  partially,  the  child  should  still  be  put  to  the 
breast,  but  at  longer  intervals  than  usual.  If  unsatisfied,  it  should 
be  fed  artificially  immediately  afterwards.  The  mother's  diet 
should  contain  a  good  proportion  of  liquid,  especially  of  milk  or 
gruel  made  with  milk,  cocoa,  and  chocolate,  and  should  be  as  ample 
and  nutritious  as  possible.  Among  other  articles  of  diet  which 
have  been  especially  recommended  are  fish,  especially  oysters, 
leguminous  foods,  such  as  peas,  beans  or  lentils,  the  latter  in  the 
form  of  revalenta  arabica,  and  stout  in  moderation.  Pilocarpin 
in  small  doses  is  sometimes  of  service,  but  as  a  general  rule  the  use 
of  so-called  galactagogues  is  disappointing. 

It  has  been  proved  that  the  develoimient  of  the  breasts  and  the 
secretion  of  milk  does  not  depend,  or  does  not  depend  solely,  upon 
an  influence  transmitted  through  the  nerves,  but  rather  upon  an 
internal  secretion.  For  the  mammary  gland  of  a  young  rabbit  has 
been  transplanted  to  its  ear.     Later  on,  after  parturition,  the  gland 

'  Quoted  by  Non-is,  American  Text-Book  ObKtclricfi,  1902,  Vol.  IF.,  p.  2'J7. 


II04  The  Practice  of   Midwifery. 

secreted  milk  five  months  after  the  operation.^  On  the  theory  that 
this  internal  secretion  is  derived  from  the  ovary,  and  that  it  is 
utilised  during  pregnancy  in  the  foetal  circulation,  and  after  parturi- 
tion has  a  more  complete  effect  upon  the  breasts,  the  administra- 
tion of  ovarian  extract,  or,  still  better,  of  extract  of  corpus  luteum, 
appears  to  be  indicated  when  the  secretion  of  milk  is  deficient. 
On  the  other  hand,  as  the  result  of  some  elaborate  experiments 
Starling^  has  concluded  that  the  growth  of  the  mammary  glands 
during  pregnancy  is  due  to  the  action  of  a  specific  chemical  stimulus 
produced  in  the  body  of  the  fcetus  and  carried  thence  into  the 
maternal  circulation.  The  removal  of  this  stimulus  after  delivery 
leads  to  the  breaking  down  of  the  built-up  tissues,  and  in  the  case 
of  the  mammary  gland  to  the  formation  and  secretion  of  the  milk. 

Polygalactia. — Some  excess  in  the  quantity  of  normal  milk  at 
the  commencement  of  lactation  is  not  uncommon.  The  excess  then 
generally  escapes  spontaneously.  An  equilibrium  is  usually  soon 
attained  through  the  increased  appetite  of  the  infant ;  and  the  only 
treatment  necessary  is  to  limit  somewhat  the  amount  of  liquid  taken 
and  keep  the  bowels  acting  rather  freely  by  means  of  salines. 

Galactorrhcea. — The  term  "  galactorrhoea  "  is  applied  to  those 
cases  in  which  there  is  not  only  a  persistent  excess  of  milk,  but  the 
milk  itself  is  thin  and  deficient  in  solids.  This  is  generally  a  sign, 
that  the  woman  is  in  a  debilitated  condition,  and  unfit  for  suckling. 
Continual  escape  of  such  a  thin  secretion  has  been  observed  not 
only  in  nursing  women,  but  sometimes  in  those  who  have  weaned, 
or  have  not  suckled,  or  even  during  pregnancy. 

Both  breasts  as  a  rule  are  at  fault.  The  causation  has  been 
ascribed  to  paralysis  of  the  muscular  fibres  surrounding  the  lacteal 
ducts  or  to  extreme  physical  exhaustion  on  the  part  of  the  woman. 
In  some  instances  the  condition  appears  to  be  associated  with 
atrophy  of  the  uterus. 

Results. — The  strength  is  soon  reduced  by  the  drain  upon  the 
system.  There  is  generally  loss  of  flesh,  while  shortness  of  breath  and 
other  signs  of  anaemia  quickly  appear.  Some  impairment  of  sight 
is  common,  and  phthisis  may  supervene,  and  lead  to  a  fatal  result. 
The  infant  also  does  not  thrive  upon  the  poor  milk.  Sometimes 
menstruation  returns  in  conjunction  with  the  galactorrhoea,  and 
may  be  excessive  in  quantity.  The  exhausting  effect  is  then 
increased. 

1  Eibbert,  Arch.  f.  Entwickelungs  Mechanik,  1899,  vii.  688. 

2  Lancet,  Croonian  Lectures,  1905. 


Diseases  of  the  Breast.  1105 

Treatment. — The  child  should  be  weaned,  both  for  its  own  sake 
and  the  mother's.  If  the  flow  of  milk  still  persists  after  suckling 
has  been  discontinued,  firm  continuous  pressure  should  be  made 
upon  the  breasts.  This  may  be  carried  out  in  the  manner 
described  at  p.  408.  At  the  same  time  glycerine  of  atropine  may 
be  applied  to  the  breasts,  or  belladonna  or  atropia  may  be  given 
internally.  If  these  means  do  not  readily  succeed,  a  few  full  doses 
(gr.  X.  to  XX.)  of  iodide  of  potassium  may  be  given.  In  some 
cases  large  doses  of  ergot  appear  to  have  a  good  effect.  To  recruit 
the  strength,  tonics,  especially  iron  and  quinine,  and  change  of  air 
are  desirable. 

Depressed  Nipples. — Flat  or  depressed  nipples  may  be  due  to 
some  extent  to  defective  development,  but  are  generally  the  result 
of  the  pressure  of  stays.  The  child,  not  being  able  to  suck  readily, 
may  eventually  refuse  the  breast  altogether,  or  may  cause  much 
pain,  or  produce  excoriations  or  fissures  by  its  efforts. 

Treatment. — In  this  condition  good  may  often  be  effected  by 
drawing  out  the  nipples  by  means  of  a  breast-glass  attached  to  an 
india-rubber  tube  and  mouthpiece,  and  having  a  reservoir  into 
which  the  milk  falls.  If,  even  after  this,  the  infant  is  still  unable 
to  suck  in  the  natural  way,  it  may  be  able  to  suck  through  a  glass 
nipple-shield  to  which  is  attached  an  india-rubber  nipple,  like  that 
of  a  feeding-bottle. 

Excoriations  and  Fissures  of  the  Nipples. — Excoriations  and 
fissures  are  most  common  in  primiparae,  in  whom  the  skin  is  gene- 
rally more  tender.  They  are  also  more  liable  to  occur  when  the 
nipples  are  dej)ressed,  or  when  there  is  a  deficiency  of  milk,  so  that 
the  infant  has  to  make  unusual  efforts  in  sucking.  They  are  pro- 
moted by  any  want  of  cleanliness  or  want  of  care  in  drying  the 
nipples  either  in  pregnancy  or  lactation. 

Excoriations  are  generally  situated  near  the  apex  of  the  nipple: 
They  may  commence  by  elevation  of  the  macerated  epithelium  in 
a  small  vesicle,  which  bursts,  leaving  the  underlying  epithelium 
exposed.  If  such  an  excoriation  or  erosion  is  continuously  irritated, 
it  may  proceed  to  the  formation  of  a  small  ulcer  or  fissure,  and 
cause  actual  loss  of  substance  of  the  nipple.  Fissures  are  generally 
transverse  at  the  base  of  the  nipple.  Both  excoriations  and  fissures 
may  bleed.  Fissures  at  the  base  of  the  nipple  are  particularly 
painful  and  difficult  to  heal,  since  they  are  liable  to  be  pulled  open 
each  time  that  the  child  is  suckled.  The  child  then  swallows  the 
blood  with  the  milk,  and  may  vomit  it  again  afterwards.  It  will 
M.  70 


iio6  The  Practice  of   Midwifery. 

:also  be  passed  per  rectum,  and  thus  constitute  one  of  the  forms  of 
melaena  in  the  infant. 

Both  excoriations  and  fissures  are  apt  to  cause  great  agony  in 
suclding,  and  make  the  mother  dread  the  application  of  the  child 
to  the  breast.  Even  a  very  minute  fissure  may  cause  this  intense 
suffering  ;  and  hence  it  is  necessary  to  make  a  very  careful  exami- 
nation whenever  pain  in  suckling  is  complained  of.  These  conditions 
of  the  nipple  are  among  the  most  important  causes  of  inflammation 
and  abscess  of  the  breast.  Among  433  women  confined  at  the 
Baudelocque  Clinique  Dluski  found  181  cases,  or  41  per  cent.,  of 
fissure  of  the  nipple,  99  of  which  were  but  slight.^ 

Propliylaxis. — During  pregnancy  the  nipples  should  be  washed 
frequently  with  bland  soap  and  water,  and  the  epithelium  should 
not  be  allowed  to  accumulate,  so  as  to  leave  tender  spots  on  its 
detachment.  In  primiparse,  especially  if  the  nipples  are  tender,  it 
is  desirable  to  treat  them  on  alternate  days  during  the  last  month 
of  pregnancy  by  inunction  with  pure  lanoline,  the  nipple  being,  if 
necessary,  drawn  out  between  the  finger  and  thumb ;  and  the 
application  of  a  mixture  of  spirit  and  eau  de  cologne  or  glycerine  of 
tannin.  During  lactation  the  nipples  should  be  carefully  washed 
and  dried  after  each  time  of  suckling,  and  a  little  glycerine  of  borax 
applied.  The  following  ointment  may  also  be  employed  for  the 
same  purpose  :  tinct.  benzoini  co.,  gr.  xv.,  olei  olivse,  gii. ;  lano- 
line, gvi. 

Treatment. — The  lotion  recommended  by  Playfair,  consisting  of 
half  an  ounce  of  sulphurous  acid,  half  an  ounce  of  glycerine  of 
tannin,  and  an  ounce  of  water,  often  does  great  good,  or  a  small 
^iece  of  lint  soaked  in  1  in  1,000  perchloride  of  mercury  solution 
may  be  kept  applied.  Compound  tincture  of  benzoin  painted  on  to 
the  nipple  is  a  very  useful  application,  or  the  fissures  and  excoria- 
tions may  be  touched  once  a  day  with  a  solution  of  nitrate  of  silver 
(gr.  x.  ad  ji.).  Some  recommend  touching  with  the  solid  stick  of 
nitrate  of  silver,  and  this  is  esi^ecially  useful  in  the  case  of  deep 
fissures,  care  being  taken  that  the  silver  nitrate  is  applied  only  to 
the  raw  surface.  It  is  frequently  found  that  less  pain  is  produced 
if  the  child  sucks  through  a  glass  nipple  shield.  This  plan  does 
not,  however,  answer  so  well  for  fissures  at  the  base  as  for  excoria- 
tions at  the  apex  of  the  nipple.  If  the  fissures  or  excoriations  do 
not  otherwise  heal,  suckling  with  the  affected  breast  should  be 
discontinued  for  a  day  or  two.  This  will  generally  allow  them  to 
heal  without  putting  an  end  to  lactation  altogether.  During  this 
time,  if  the  breasts  become  distended  and  painful  and  drawing  off  of 

1  These  de  Paris,  1894. 


.    Diseases  of  the  Breast.  1107 

some  of  the  milk  with  a  breast-pump  causes  too  much  pain,  gentle 
massage  of  the  breast  from  the  periphery  to  the  centre  may  be 
carried  out  until  the  milk  flows  from  the  nipple. 

Mastitis  :  Mammary  Abscess. — At  the  time  when  the  secretion 
of  the  milk  commences  it  is  common,  especially  in  primiparse,  for 
the  breasts  to  become  unequally  swollen,  knotty,  and  painful.  This 
condition  arises  from  obstructions  in  the  lacteal  ducts,  preventing  a 
free  outflow  of  the  secretion  (caked  breasts).  When  the  child  has 
been  lost,  and  the  breasts  are  therefore  not  relieved  by  its  sucking, 
the  glands  may  be  more  uniformly  affected  in  a  similar  way.  In 
either  case,  the  condition  may  amount  to  actual  inflammation. 
There  may  be  elevation  of  temperature  and  pulse,  as  well  as  local 
pain,  swelling,  and  tenderness,  and  sometimes  even  rigors  occur. 
Thickened  lymphatics  may  be  traced,  running  to  the  axilla, 
and  the  axillary  glands  may  become  swollen.  It  is  very  rare, 
however,  for  this  form  of  inflammation,  without  other  cause,  to 
go  on  to  the  formation  of  abscess,  and  it  almost .  always  ends  in 
resolution. 

Abscess  in  the  breast,  in  the  great  majority  of  cases,  is  due  to 
excoriation  or  fissure  of  the  nipples.  Probably  in  most  cases  the 
lacteal  ducts  become  affected,  in  consequence,  by  catarrhal  inflam- 
mation, and  at  the  same  time  obstructed,  microbes  of  suppuration 
having  found  an  entrance  from  without.  The  inflammation  extends 
backward  along  the  ducts  to  the  lobules  of  the  gland  ;  thus  a  portion 
only  of  the  gland  is  affected  as  a  rule  (parenchymatous  mastitis). 
Small  collections  of  pus  are  formed  at  first  ;  these  unite  and  form 
a  larger  abscess  cavity.  Not  infrequently,  after  the  opening  of  a 
first  abscess,  one  or  more  subsequent  abscesses  are  formed  in  other 
lobules,  different  foci  of  inflammation  having  suppurated  in 
succession.  In  other  cases,  the  inflammation  may  extend  from 
the  nipple,  not  along  the  lacteal  ducts,  but  through  the  cellular 
tissue,  chiefly  by  the  lymphatics  (interstitial  mastitis). 

Abscess  of  the  breast,  in  accordance  with  the  view  given  above 
as  to  its  causation,  rarely  appears  within  the  first  few  days  after 
delivery.  More  frequently  it  occurs  about  the  third  or  fourth  week, 
and  sometimes  even  at  a  later  period.  It  occurs  chiefly  in  ansemic 
and  debilitated  women.  Those  cases  which  do  not  commence 
within  the  first  two  months  after  delivery  are  observed  chiefly  in 
women  who  are  weakened  by  prolonged  lactation,  as,  for  instance, 
when  suckling  is  prolonged  for  eighteen  months  or  more — a  not 
uncommon  case  among  the  lower  classes.  Sometimes  an  abscess 
has  followed  sudden  cessation  of  suckling,  when  the  glands  are  in 

70—2 


iio8  The  Practice  of  Midwifery. 

full  activity.  Occasionally  it  has  been  observed  in  pregnancy,  or 
in  women  not  suckling  their  children.  In  rare  cases,  a  blow  or 
other  injury  appears  to  be  the  starting-point  of  the  inflammation. 
In  still  more  rare  cases,  abscess,  or  even  sloughing,  of  the  breast, 
forms  a  part  of  a  general  septic  infection,  and  occurs  shortly  after 
delivery. 

The  organism  most  commonly  present  in  the  pus  of  a  mammary 
abscess  is  the  Staphylococcus  aureus  or  albus,  occasionally  the 
streptococcus,  while  at  times  the  infection  is  a  mixed  one.  The 
mode  of  entrance  is  usually  through  a  crack  in  the  nipple,  and 
the  source  of  origin  may  be  the  child's  mouth,  the  neighbouring 
skin,  the  fingers  of  the  patient  or  of  the  nurse,  or  soiled  dressings 
and  nipple  shields.  When  a  fissure  of  the  nipple  is  present  the 
organisms  pass  into  the  tissues  by  the  lymphatics,  while  when  the 
nipple  is  intact  their  mode  of  entrance  is  through  the  lacteal  ducts. 
In  a  few  rare  cases  they  find  their  way  to  the  breast  from  the  blood, 
as,  for  example,  in  the  variety  of  metastatic  mammary  abscess. 

According  to  Bumm,^  the  organisms  set  up  fermentative  changes 
in  the  milk,  the  sugar  being  converted  into  lactic  and  butyric  acids 
and  the  casein  coagulated.  Shedding  of  the  glandular  epithelium 
takes  place,  and  a  leucocytic  infiltration  of  the  periglandular  tissues 
with  the  formation  of  localised  collections  of  pus. 

The  most  common  form  of  inflammation  leading  to  abscess  is 
that  in  which  the  glandular  substance  and  areolar  tissue  of  a  portion 
of  the  mamma  are  involved  in  inflammation  together.  The  lacteal 
ducts  belonging  to  the  affected  acini  become  obstructed.  Sometimes, 
as  the  abscess  enlarges,  it  may  burst  into  a  large  lacteal  duct.  The 
pus  may  then  be  discharged  from  the  nipple  with  the  milk  ;  or,  if 
the  abscess  also  opens  externally,  a  lacteal  fistula  may  remain  at 
the  point  of  opening,  through  which  the  milk  escapes,  and  which 
sometimes  is  found  difficult  to  close. 

Symptoms  and  Course. — The  inflammation  begins  with  acute  pain 
and  pretty  severe  constitutional  symptoms.  There  is  considerable 
elevation  of  pulse  and  temperature,  general  malaise,  and  usually 
rigors  at  the  commencement  of  suppuration.  The  temperature 
often  subsides  somewhat  after  a  few  days,  but  pain  usually  con- 
tinues until  the  pus  has  escaped.  A  hard  and  very  tender  swelling 
is  found  at  the  site  of  inflammation. 

As  the  case  progresses,  the  skin  becomes  reddened,  and  eventually 
glazed  and  cedematous,  and  fluctuation  becomes  manifest  as  the 
pus  apj)roaches  the  surface.  If  the  abscess  is  left  to  nature,  it  often 
bursts  by  a  small  opening ;   the  pus  does  not  escape  freely,  and  the 

1  Sammlung  Klin.  Vortrage,  1886,  No.  282. 


Diseases  of  the  Breast.  1109 

different  foci  of  suppuration  communicate  also  by  narrow  openings. 
A  large  part  of  the  mamma  may  thus  be  undermined.  Openings 
may  also  take  place  at  several  points,  and  the  breast  may  thus 
become  riddled  with  fistulous  tracts.  In  such  cases  suppuration 
may  continue  for  months,  and  the  strength  be  greatly  reduced. 
When  the  patient  is  exposed  to  insanitary  conditions,  sloughing  of 
undermined  tissue  may  take  place,  and  haemorrhage  may  occur 
from  vessels  laid  open. 

Supra-mammary  Abscess. — Sometimes  the  inflammation  affects, 
not  the  gland  tissue  itself,  but  the  areolar  tissue  over  it.  The 
starting-point  is  the  nipple,  or  some  of  the  small  glands  surround- 
ing it,  and  either  the  areola  only  may  be  involved,  or  the  cellular 
tissue  over  a  wider  surface.  A  superficial  abscess,  generally  of  no 
great  size,  is  thus  formed. 

Sub-mammary  Abscess. — In  other  cases,  the  site  of  abscess  forma- 
tion is  the  layer  of  areolar  tissue  beneath  the  breast.  Inflammation 
generally  spreads  to  this  from  the  deeper  portion  of  the  gland 
itself.  The  abscess  is  then  usually  extensive.  The  whole  mamma 
becomes  prominent :  there  is  deep-seated  pain  and  tenderness, 
but  not  so  much  superficial  tenderness ;  pain  on  movement  of  the 
arm  is  greater  than  in  ordinary  mammary  abscess.  The  abscess 
generally  opens  at  the  border  of  the  gland,  toward  the  outer  and 
lower  part,  often  in  several  places.  This  variety  is  the  rarest 
of  all. 

Treatment. — If  there  are  signs  of  inflammation  on  the  first 
establishment  of  the  secretion  of  milk,  saline  laxatives,  such  as 
sulphate  of  magnesia,  are  to  be  given.  If  the  child  is  to  be  suckled, 
gentle  frictions  with  oil  in  the  direction  of  the  nipple  are  to  be 
employed.  If  the  child  is  feeble  in  sucking,  a  little  milk  may 
be  drawn  now  and  then  with  a  breast-glass,  with  a  view  to  clearing 
the  ducts.  If,  however,  the  child  is  dead,  it  is  better  to  treat  with 
belladonna  or  atropia,  and  apply  firm  pressure  in  the  mode  already 
described  (see  p.  408). 

When  abscess  is  threatened,  the  first  essential  is  to  take  away  the 
child  from  the  breast — at  any  rate,  from  the  side  affected.  If 
necessary,  some  milk  may  be  squeezed  from  the  affected  side  by 
gentle  pressure  or  massage,  or  a  little  may  be  drawn  off  by  the 
breast-glass.  Saline  aperients  should  be  given,  and  opiates  for 
the  relief  of  pain.  Fomentatives  or  poultices  give  much  relief, 
but  they  should  not  be  used  so  long  as  there  is  a  hope  of  avoiding 
suppuration,  nor  after  the  abscess  has  been  opened.  In  the  latter 
case  they  cause  maceration  of  the  skin  and  prolong  the  suppuration. 
Strict  rest  should  be  maintained.     The  patient  sliould  be  kept  in 


mo  The  Practice  of   Midwifery. 

bed,  and  the  arm  kept  to  the  side.  Gentle  uniform  pressure  is  also 
useful.  This  may  be  applied  by  carefully  strapping  the  breast,  the 
strapping  not  being  warmed  at  the  fire,  but  dipped  in  hot  water,  so 
that  it  may  become  more  pliable,  and  adapt  itself  more  completely 
to  the  shape  of  the  breast.  At  this  stage  it  is  better  to  use  cold 
than  heat.  Dry  cold  may  be  applied  by  means  of  a  bag  of  ice,  or 
a  Leiter's  temperature  regulator,  through  which  a  stream  of  ice- 
cold  water  is  kept  running. 

The  stage  at  which  fomentatives  are  useful  is  when  it  is  clear  that 
suppuration  has  commenced,  or  is  inevitable,  but  the  pus  is  not  yet 
near  enough  to  the  surface  to  be  evacuated.  As  soon  as  it  is  obvious 
that  an  abscess  has  formed  it  should  be  opened.  In  some  cases, 
when  there  is  an  unusually  deep  abscess  and  severe  constitutional 
symptoms,  it  may  be  well  to  explore  first  with  an  aspirator 
needle. 

The  abscess  should  be  opened  with  antiseptic  precautions,  and  an 
anaesthetic  given  as  a  general  rule.  The  line  of  incision  should 
radiate  from  the  nipple,  so  as  not  to  divide  the  lacteal  ducts.  The 
incision  should  be  fairly  deep  and  wide,  and  all  the  pus,  with  any 
loose  shreds  of  tissue,  should  be  squeezed  out  by  gentle  pressure. 
The  cavity  is  then  irrigated  with  a  weak  antiseptic  solution, 
such  as  peroxide  of  hydrogen,  boracic  acid,  or  i  per  cent,  lysol.  The 
cavity  should  then  be  packed  with  antiseptic  or  sterile  gauze  and 
covered  with  an  antiseptic  or  aseptic  dressing  in  the  usual  way 
under  a  firm  bandage.  When  the  dressing  is  changed  the  cavity 
should  be  lightly  packed  again  and  this  treatment  continued  until 
it  has  healed.  Drainage  tubes  may  be  used  instead  of  the  gauze  if 
they  are  preferred,  but  closure  of  the  cavities  usually  takes  place 
more  rapidly  with  the  use  of  gauze  plugs. 

A  superficial  supra-mammary  abscess  is  easily  opened  by  a  free 
incision  radiating  from  the  nipple.  It  is  better  not  to  include  the 
areola  in  the  incision,  if  it  can  be  avoided,  lest  the  nipple  be  drawn 
aside  by  a  cicatrix.  A  sub-mammary  abscess  should  be  opened,  if 
possible,  toward  the  outer  and  lower  part.  An  exploring-needle 
may  be  required,  to  make  sure  of  the  locality  of  the  pus. 

Tonic  treatment,  esjDecially  quinine  and  iron,  will  be  called  for, 
and  the  strength  should  be  supported  by  nutritious  diet.  In  general 
it  is  better  to  wean  the  infant  altogether. 

If  the  abscess  has  been  neglected  in  the  first  instance,  and  the 
suppuration  is  prolonged,  and  fistulous  openings  remain,  the  open- 
ings may  be  enlarged,  the  finger  passed  in  to  break  down  partitions 
in  the  abscess  cavity,  and  gauze  plugs  or  drainage  tubes  introduced. 
The  cavity  may  be  washed  out  at  intervals  with  a  solution  of  iodine 


Diseases  of  the  Breast.  1 1 1 1 

(tr.  iodi.  5ii.  ad,  aq.  Oi.),  or  chinosol  (1  in  2,000).     Closure  of  the 
sinuses  is  promoted  by  well-adjusted  pressure. 

Galactocele. — In  very  rare  cases  a  collection  of  milk  is  formed 
through  obstruction  of  one  of  the  lacteal  ducts.  After  a  time  the 
milk  generally  becomes  thick  and  cheesy,  through  absorption  of 
the  watery  portion,  or  it  may  separate  itself  into  a  thin  and  a 
thicker  part.  The  swelling  is  generally  only  of  moderate  size,  but 
has  been  known  to  attain  enormous  dimensions.  The  skin  may 
give  way  eventually,  or  the  cyst-wall  may  give  way,  and  the  milk 
become  extravasated  in  the  breast. 

Treatment. — The  swelling  should  be  incised,  and  the  further 
secretion  of  milk  stopped  by  weaning  the  infant. 


Index 


Abdomen,  enlargement  of,  in  pregnancy, 
173  ;  discoloration  of,  in  pregnancy,  170  ; 
in  puerperal  state,  B95  ;  palpation  of, 
in  pregnancy,  173,  273,  295  ;  pendulous, 
494  ;  stripes  upon,  in  pregnancy,  39o  ; 

■  tumours,  diagnosis  of,  from  pregnancy, 
191 

Abdominal  foetation,  primary,  434  ;  secon- 
dary, 433 
— •    hysterectomy    in    puerperal    sep- 
ticcemia,  1046 

—  palpation,  273,  295 
Abnormal  pregnancy,  417 
Abnormalities  of  uterus  in  pregnancy,  493 
Abortion,  566 ;  causation,  569  ;  symptoms 

and  course,  572  ;  diagnosis,  575  ;  prog- 
nosis, 577  ;  treatment,  579  ;  incomplete 
treatment  of,  585  ;  missed,  521 

Abortion,  artificial,  induction  of,  803  ;  in 
vomiting  of  pregnancy,  459  ;  in  chorea, 
464  ;  in  albuminuria,  473  ;  in  cancer  of 
cervix  uteri  and  pelvis,  651  ;  in  con- 
tracted pelvis,  is,  759  ;  operation  for, 
805 

Abscess,  mammary,  894  ;  in  pelvic  cel- 
lulitis, 1024  ;  in  phlegmasia  dolens, 
1051  ;  in  puerperal  peritonitis,  1018  ; 
in  puerperal  pysemia,  1021 

Acardiac  acephalic  monster,  369,  685 

Accidental  complications  of  pregnancy, 
551 

—  hEemorrhage,  608  ;  plugging  vagina 

in  cases  of,  614  ;  treatment,  613 
Achondroplasia,  544  ;  effects  on  pelvis,  724 
Adaptation  of  foetus  to  uterus,  142 
vVfter-coming  head,  extraction  of,  361  ;  in 
contracted  pelvis,  749  ;  application  of 
forceps  to,  859  ;  perforation  of,  901 
After-pains,  393  ;  treatment  of,  403 
Agalactia,  408,  1102 
Ague,  in  pregnancy,  561 
Air,  entry  of,  into  circulation,  1057 
Albuminuria,  in  pregnancy,   465  ;  treat- 
ment,   472  ;     in     eclampsia,    477  ;    in 
accidental   hemorrhage,   608  ;    in  con- 
nection with  puerperal  insanity,  1072 
Allantois,  formation  of,  89  ;  function  of, 

89 
Amnion,  formation  of,  80  ;  structure,  86  ; 

dropsy  of,  531 
Amniotic  fluid,  87.     (>See  Liquor  amnii.) 
Amputation,  intra-uterine,  of  limbs,  539 
Anasmia,  in  pregnancy,  461 


Ansesthesia,  in  normal  labour,  314  ;  in 
version,  866 

Anatomy  of  foetal  head,  127  ;  of  ovaries, 
39  ;  of  pelvis,  1  ;  of  placenta,  96 

Anencephalic  monster,  686 

Anencephalus,  540 

Anodynes  in  the  first  stage  of  labour,  315. 
(^See  Narcotics.) 

Anteflexion  and  anteversion  of  gravid 
uterus,  494 

Antiseptic  precautions  in  labour,  291  ;  in 
lying-in  hospitals,  1032 

Antistreptococcic  serum,  1038 

Anus,  laceration  of  sphincter  of,  956 

Apoplexy  of  new-born  infant,  1084 

Appendicitis  in  pregnancy,  558 

Areola,  mammary,  in  pregnancy,  165 

Arm,  dorsal  displacement  of,  679  ;  libera- 
tion of,  in  pelvic  presentations,  749,  815; 
presentation  of,  677 — 679  ;  presenta- 
tion of,  with  head,  677 

Articulations,  pelvic,  10 ;  inflammation 
of,  1013,  1021  ;  rupture  of  pelvic,  in 
lalDour,  958  ;  relaxation  of  pelvic,  in 
pregnancy,  12 

Artificial  human  milk,  413 

—  feeding  of  infant,  410 

—  respiration,  in  asphyxia   neonato- 

rum, 1090 
Ascites,  foetal,  692 
Asphyxia  neonatorum,  1085  ;   treatment, 

1089 

—  of  foetus,  indications  of,  in  pelvic 

presentation,  361,  808 

Atresia  of  cervix,  645  ;  of  vagina  and 
vulva,  646 

Auscultation,  in  pregnancy,  184 — 190  ;  in 
twin  pregnancy,  372 

Autogenetic  septicsemia,  997 

Auxiliary  forces  in  labour,  235  ;  in- 
efficiency of,  625 

Aveling's  forceps,  827 ;  rcpositor  for 
inversion  of  uterus,  970 

Axes  of  pelvis,  20,  22 

Axis,  deviation  of  uterine,  in  labour,  625 

Bacteria  in  puerperal  fever,  993,  991, 

995 
Ballottement,  181 
I'andl,  ring  of,  156,  621 
Barnes'  dilator,  638 
Basilyst,  Simpson's,  897 
Battledore  placenta,  512 


1 1 14 


Index. 


Bed-ridden  pelvis,  785 
Bimanual   examination,    in    early   preg- 
nancy, 174 

—  version,  864 

Binder,  application  of  abdominal,  313 

Biparietal  obliquity  of  foetal  head,  262, 
727 

Bipolar  version,  866 ;  in  shoulder  pre- 
sentation, 872 

Bladder,  calculus  in,  obstructing  labour, 
659  ;  distension  of,  obstructing  labour, 
659  ;  distension  of  foetal,  692 

Blastocyst,  70 

Blood,  changes  of,  in  pregnancy,  167 

—  pressure  in  pregnancy.  167 
Blunt  hook,  in  breech  presentation,  813 
Bossi's  uterine  dilator,  641 

Bougie,  use  of   flexible,  in  induction  of 

labour,  794 
Brain,  embolism  of,  1057 
Braxton  Hicks'  cephalotribe,  892 
Breasts,    areola    of,    165 ;     care    of,    in 

puerperal  state,   407  ;   changes   of,   in 

pregnancy,    164;     diseases    of,    1103; 

abscess  of,  1107 
Breech   presentations,   345.     {See   Pelvic 

presentations.) 
Bregma,  129 
Brim  of  pelvis,  4 
Bronchocele,  in  pregnancy,  557 
Brow  presentations,  322,  339  ;  treatment 

of,  343  ;  use  of  vectis  in,  823 
Budin's  catheter,  588,  1035 


Cadaveric  poison,  in  causation  of  puer- 
peral septicajmia,  993,  1004 

Csesarean  section,  903  ;  in  accidental 
h<emorrhage,  616  ;  in  cancer  of  cervix 
uteri  and  pelvis,  651  ;  in  contracted 
pelvis,  751  ;  extraperitoneal,  915  ; 
description  of  operation,  906  ;  uterine 
sutures  in,  909  ;  anassthetics  in,  905  ; 
post-mortem  operation,  916  ;  Porro's 
operation,  916 ;  Sanger's  operation, 
904  ;  suprasymphyseal,  915  ;  vaginal, 
922 

Calcareous  degeneration  of  foetus,  440 

Calculus,  vesical,  obstructing  labour,  659 

Canalized  fibrin,  107,  510 

Cancer  of  cervix  uteri  and  pelvis,  648  ; 
treatment,  649 

Caput  succedaneum,  in  cranial  presenta- 
tion, 225,  272  ;  in  face  presentation, 
336  ;  diagnosis  of,  from  cephalhtema- 
toma,  1079 

Carcinoma,  648.     (See  Cancer.  J 

Cardiac  diseases  complicating  pregnancy, 
551 

Carneous  mole,  519  ;  treatment,  522  Qsee 
547) 

Carunculfe  myrtiformes,  194 

Caul,  222,  694 

Cellulitis,  pelvic,  1021.  (^See  Pelvic 
cellulitis.) 


Centres,  motor,  for  uterine  contraction, 

207 
Cephalhfematoma,  1079 
Cephalic  version,  861 
Cephalotribe,  892 

Cervix  uteri,  apparent  shortening  of,  in 
pregna«.cy,  159 

—  artificial   dilatation  of,   in   labour, 

637  ;  for  induction  of  abortion, 
805  ;  for  induction  of  premature 
labour,  797 ;  in  vomiting  of 
pregnancy,  459 

—  atresia  of,   646 ;    cancer   of,    648 

changes   of,  in   pregnancy,   155 
180;    dilatation    of,    217,    223 
ganglion  of,  209  ;  incision  of,  644 
652  ;    in   placenta  prfevia,  599 
in  puerperal  state,  390  ;    lacera- 
tion of,  948  ;  mode  of  expansion 
of,  in  labour,  223  ;    rigidity  of, 
635 
Chamberlen's  forceps,  823 
Champetier  de  Ribes'  dilator,  605,  640 
Child,  new-born,  399.     (&e  Infant.).   . 
Cholera  in  pregnancy,  565 
Chondrodystrophia  foetalis,  544,  724 
Chondrodystrophic  pelvis,  724 
Chorea,  in  pregnancy,  463 
Chorion,  formation  of,  92  ;  hydatidiform 
degeneration   of,    523  ;  diseases    of,    as 
a     cause     of     abortion,      571.       {See 
Placenta.) 
Chorionepithelioma,  530,  1061 
Cicatrices  obstructing  labour,  646 
Circulation,   changes    of,   in    pregnancy, 
166  {see  551) ;  of  foetus,  121  ;  change  of 
foetal,  at  birth,  123 
Coccyx,  2  ;  mobility  of,  16,  20,  22 
Coiling   of    funis,    537 ;    as    a    cause    of 

obstruction  to  labour,  695 
Collapse  after  labour,  1060 
Colostrum,  394 
Colpeurynter,  801 

Compound  presentations,  677,  678,  679 
Conception,   61  ;  in  multiple  pregnancy, 

367 
Conjugate  diameter  of   pelvic   brim,  16, 

704  ;  diagonal,  705 
Constipation,  in  pregnancy,  458 
Contracted  pelves,  697.     {See  Pelvis.) 
Contraction,     pelvic,     effects     of,     upon 
pregnancy,    736  ;    upon   labour, 
737 
— •     uterine,  206,  209  ;    in  pregnancy, 
180  ;    nerve    centre    for,    207 
nervous     mechanism     of,     206 
hour-glass,      of      uterus,      976 
irregular,  of  uterus,  624 
Convulsions,       puerperal,      474.         {See 

Puerperal  eclampsia.) 
Cord,  umbilical.  111.     {See  Fxxnis.) 
Corpus  luteum,  55 
Cramps  in  labour,  214 
Cranial  presentations,  239 
Cranioclasm,  898 


Index. 


1115 


Craniotomy,    indications    for,    883  ;    de- 
scription   of      operation,     886  ; 
methodsof  extraction,  888  ;  with 
after-coming  head,  901 
—     forceps,  888 
Grade's  method  of  expressing  placenta,  309 
Crochet,  900 

Crowning,  stage  of,  in  labour,  229 
Crural  phlebitis,  10i8.     (^See  Phlegmasia 

dolens.) 
Curette,  use  of,  in  abortion,  587 
Cysts,  in  vesicular  mole,  523  ;    ovarian, 
657.     (See  Ovarian  tumours.) 


Death,  apparent,  of  new-born  child, 
1085  ;  foetal,  diagnosis  of,  192  ;  foetal, 
causing  abortion,  570  ;  intra-uterine, 
of  foetus,  514  ;  sudden,  during  or  after 
delivery,  1052,  1060 

Decapitation,  after  failure  of  version, 
674 ;  mode  of  performing,  675  ;  for 
locked  twins,  682 

Decidua,  development  of,  70  ;  diseases  of, 
510  ;  disease  of,  as  a  cause  of  abortion, 
571 

Decidual  endometritis,  510 

Deciduoma  malignum,  530,  1061  ;  diag- 
nosis, 1068  ;  treatment,  1068 

Deformities,  pelvic,  697.     (iSee  Pelvis.) 

Degeneration,  of  foetus,  440  ;  calcareous, 
of  foetus,  440  ;  of  placenta,  519  ;  hyda- 
tidiform,  of  chorion,  523 

Delivery,  care  of  patient  after,  403  ;  mode 
of  calculating  date  of,  197  ;  state  of 
patient  after,  403  ;  signs  of  recent,  395 

Development,  early,  of  ovum,  65  ;  of 
amnion,  80  ;  of  allantois,  89  ;  of  pelvis,  25 

Diabetes,  in  pregnancy,  556 

Diagonal  conjugate  diameter  of  pelvis,  705 

Diameters,  of  normal  pelvis,  16  ;  of  foetal 
head,  130 

Diarrhoea,  in  pregnancy,  460  ;  in  puer- 
peral septicaemia,  1017 

Diet,  in  pregnancy,  201 ;  in  puerperal 
state,  40.3,  1037 

Digestion,  disorders  of,  in  pregnancy,  460 

Digital  examination  in  labour,  273,  278 

Dilatation,  manual,  of  cervix,  641 

Dilators,  hydrostatic,  605,  638  ;  Barnes  s, 
638  ;  Champetier  de  Ribes',  640,  799  ; 
Bossi's,  641  ;  Frommer's,  642  ;  in 
eclampsia,  489  ;  in  placenta  previa, 
605  ;  in  rigidity  of  cervix,  638  ;  for 
induction  of  premature  labour,  799 

Diphtheria,  relation  of,  to  puerperal 
fever,  1002 

Diphtheritic  deposits  in  puerperal  septi- 
C!cmia,  1007 

Diseases  of  pregnancy,  455 ;  zymotic, 
accidentally  complicating  pregnancy, 
562  ;  zymotic  relation  of,  to  puerperal 
fever,  KXJl 

Disinfecting  clothes  in  cases  of  puerperal 
fever,  1031 


Dislocations,  so-called  congenital,  539, 
734  (.see  819) 

Displacements  of  uterus,  in  pregnancy, 
494 ;  as  a  cause  of  protracted  labour, 
625  ;  as  a  cause  of  rupture  of  uterus  or 
vagina,  938  ;  in  puerperal  state,  991 

Doable  uterus,  377 

Douche.     {See  Injections.) 

Drainage  tube,  in  mammary  abscess,  1110  ; 
in  pelvic  abscess,  1044 

Dropsy  of  amnion,  531  ;  general,  688. 
(>S'ee  (Edema.) 

Ductus  arteriosus,  121  ;  venosus,  121 

Duration  of  pregnancy,  195 


ECLA-MPSIA,      474.         {See       Puerperal 

eclampsia.) 
Ectopia  of  viscera,  541,  686 
Elbow,  diagnosis  of,  from  knee,  667 
Electricity  in  asphyxia  neonatorum,  1094 
Elytrotomy,    in   extra-uterine    foetation, 

454 
Embolism  of   pulmonary  arteries,  1052  ; 

of  systemic  arteries,  1057 
Embryo,  development  of,  115  ;  circulation 

of,  121 
Embryotomy,  676  ;  in  shoulder  presenta- 
tions, 676  ;  in  pelvic  presentations,  902 
Emphysema,  foetal,  causing  dystocia,  688  ; 

maternal,  in  violent   labour,   618  ;    in 

rupture  of  uterus,  947 
Encephalocele,  obstructing  labour,  693 
Encliondroplasia,  724 
Endocarditis  in  pregnancy,  553  ;  in  puer- 
peral septicemia,  1013 
Endometritis,  decidual,  510  ;  in  puerperal 

fevers,  1007,  1017 
Enteric  fever  in  pregnancy,  564 
Enterocele,   vaginal,   obstructing  labour, 

659 
Enucleation  of  fibroid  tumours  in  labour, 

656 
Epiblast,  69 
Episeiotomy,  648 
Epistaxis,  in  pregnancy,  558 
Epithelium   of   Graafian  follicle,  40 ;    of 

ovary,  35 
Ergot,  in  abortion,  579  ;  in  hydatidiform 

mole,  530  ;  dangers  of,  in  labour,  628  ; 

use  of,  in  labour,  628  ;  in  post-partum 

hemorrhage,  984 
Erotomania,  1075 

Eruptions  in  pregnancy,  462  ;    in  puer- 
peral fevers,  999,  1017 
Erysipelas,  in  pregnancy,  564  ;    relation 

of,  to  puerperal  fever,  999  ;  death  rates 

from,  1000,  1025 
Eustachian  valve,  121 
Evisceration  in  shoulder  presentation,  676 
Evolution,      spontaneous,      670  ;       with 

doul)led  body,  671 
Examination  in  labour,  174 
Exanthemata,  562.  (iS'ee  Zymotic  diseases.) 
Excretions  in  puerperal  state,  382 


I  ii6 


Index. 


Exhaustion  in  labour,  619 

Esomphalos,  oiO,  686 

Expression,  of  f  cetus,  628  ;  in  pelvic  pre- 
sentations, 361,  808 ;  o£  placenta, 
309 

Extension  of  foetal  head,  in  normal 
labour,  253 ;  in  the  flattened  pelvis, 
726  ;  in  face  presentation,  321  ;  of  the 
after-coming  head,  744,  749 

External  rotation,  in  normal  labour,  253  ; 

,  in  face  presentation,  332 

Extraction  of  foetus,  after  craniotomy, 
888  ;  by  feet,  808  ;  in  pelvic  presenta- 
tion, 806  ;  in  Caesarean  section,  908  ; 
after  death  of  mother,  916 

Extraction  of  head,  in  pelvic  presenta- 
tion, 361,  819 

Extra-uterine  foetation,  417.  (^See  Preg- 
nancy, abnormal.) 

Extroversion  of  viscera,  540,  686 


Face  presentation,  321  ;  frequency  of, 
323  ;  causation,  323  ;  diagnosis,  337  ; 
mechanism  of  labour  in,  32S  ;  moulding 
of  head  in,  336  ;  prognosis,  338  ;  treat- 
ment, 340  ;  varieties,  326 

Fallopian  tubes,  position  of,  43 

False  pains,  164 

Fatty  degenei'ation  of  foetus,  440 

Fecundation,  61 

Feeding,  artificial,  of  infant,  410 

Femora,  effects  of  pressure  of,  on  pelvis, 
28,  699 

Fever,  enteric,  564  ;  malarial,  561  ;  puer- 
peral {see  Puerperal  fevers),  992  ;  re- 
lapsing, 564  ;  typhus,  564 

Fibroid  tumours,  diagnosis  of,  from  preg- 
nancy, 191  ;  complicating  pregnancy, 
559  ;  as  a  canse  of  dystocia,  653 

Fillet,  soft,  in  breech  presentations,  811 

Fistula,  recto-vaginal,  739  ;  vesico-vaginal, 
738 

Flattened  pelvis,  715  ;  mechanism  of 
labour  in,  725  ;  treatment  of  protracted 
labour  in,  740  ;  rare  forms  of,  734 

Flexion  of  foetal  head  in  normal  labour, 
245  ;  in  flattened  pelvis,  726  ;  in  face 
presentation,  331 

Fluid,  amniotic,  87.     (^See  Liquor  amnii.) 

Foetal  head,  anatomy  of,  127  ;  after-com- 
ing, extraction  of,  361,  819  ;  after-com- 
ing, perforation  of,  901  ;  articulation 
of,  134  ;  descent  of,  245  ;  diameters  of, 
130  ;  effects  of  pressure  on,  739,  1080  ; 
extension  of,  253,  321,  726  ;  external 
rotation  of,  255,  332  ;  flexion  of,  245, 
331,  726  ;  fontanelles  of,  128  ;  internal 
rotation  of,  251,  329  ;  influence  of  sex 
and  race  on,  133  ;  lateral  obliquity  of, 
262  ;  moulding  of,  in  vertex  presenta- 
tion, 268  ;  in  face  presentation,  336  ; 
in  brow  presentation,  340  ;  movements 
of,  256  ;  perforation  of,  883  ;  restitution 
of,  255,  331  ;  sutures  of,  128 


Foetal  heart,  185 ;  in  twin  pregnancy,  372  ; 
in  pelvic  presentation,  188  ;  variation 
of,  according  to  sex  and  size  of  foetus , 
189 

Foetation,  extra-uterine,  417.  (^See  Preg- 
nancy, abnormal.) 

Foetus,  abnormalities  of,  obstructing 
labour,  663  ;  ascites  of,  692  ;  at  term, 
119  ;  attitude  of,  137  ;  circulation  of, 
121  ;  dead,  retention  of  in  utero,  545  ; 
death  of,  544  ;  degeneration  of,  438  ; 
development  of,  115  :  diagnosis  of 
death  of,  192, 545  ;  diseases  of,  539, 1079  ; 
emphysema  of,  688  ;  extraction  of  (.see 
Extraction),  888  ;  excessive  develop- 
ment of,  687 ;  habitual  death  of,  793  ; 
heart-sounds  of  {see  Foetal  heart),  185  ; 
hydrocephalus  of,  142,  689  ;  injuries  to, 
739,  1079  ;  maceration  of,  545  ;  move- 
ments of,  183 ;  mortality  of,  in  labour, 
319  ;  mummification  of,  545  ;  nutrition 
of,  125  ;  oedema  of,  688  ;  papyraceus, 
547  ;  positions  of,  239  ;  presentations 
of,  138  ;  putrefaction  of,  547  ;  size  of, 
in  successive  months,  115  ;  tumours  of, 
694  ;  weight  of,  120 

Follicles,  Graafian,  40  ;  of  areola,  in 
pregnancy,  165 

Fontanelles  of  foetal  head,  128  ;  recogni- 
tion of,  in  labour,  279 

Foot  presentations,  346 

Foramen  ovale,  121 

Forceps,  anassthetics  in  application  of, 
838  ;  application  of,  836  ;  to  after-com- 
ing head,  859 ;  the  author's  axis-traction, 
856  ;  Aveling's  axis-traction,  827  ; 
Barnes's,  828;  Barnes's  craniotomy,  889 ; 
Chamberlen's,  823  ;  direction  of  traction 
with,  847  ;  history  of,  823  ;  indications 
for,  630  ;  in  flattened  pelvis,  742  ;  in 
cancer  of  cervix  uteri  and  pelvis,  653  ; 
in  congenital  hydrocephalus,  691  ;  in 
face  presentation,  858  ;  in  brow  pre- 
sentation, 343  ;  in  breech  presentation, 
814  ;  in  occipito-posterior  positions,  857  ; 
in  prolapse  of  funis,  963  ;  in  placenta 
prsevia,  606  ;  in  protracted  labour,  629  ; 
in  rigidity  of  cervix,  643  ;  in  rupture  of 
uterus,  942  ;  Levret's,  824  ;  leverage 
action  of,  853  ;  locking  of,  844  ;  long 
curved,  826,  831  ;  long  straight,  825  ; 
mechanical  action  of,  828  ;  use  of  ovum, 
in  abortion,  584  ;  Roper's  craniotomy, 
889  ;  short  straight,  824  ;  short  curved, 
824  ;  Simpson's,  831  ;  Smellie's,  825  ; 
Tarnier's  axis-traction,  828,  856  ; 
author's  uterine  vulsellum,  584 

Forces  in  labour,  230  ;  auxiliary,  235 ; 
anomalies  of  expulsive,  623  ;  magnitude 
of,  237 

Fossa  navicularis,  952 

Fourchette,  laceration  of,  952 

Fractures,  causing  pelvic  deformity,  791  ; 
intra-uterine,  540  (.see  544) 

Frenum  linguae,  tightness  of,  1097 


Index. 


1117 


Frommer's  dilator,  642 

Funic  souffle,  189 

Funis,  anomalies  of,  536  ;  arteries  of,  112  ; 
care  of,  in  new-born  infant,  537  ;  coil- 
ing of,  695  ;  expression  of,  959  ;  knots 
in,  536  ;  laceration  of,  695  ;  ligature  of, 
306  ;  management  of,  in  pelvic  presen- 
tation, 360,  815  ;  marginal  insertion  of, 
512  ;  presentation  of,  959  ;  prolapse  of, 
959 ;  reposition  of,  962  ;  shortness  of, 
causing  dystocia,  695  ;  structure,  112  ; 

•  torsion  of,  538  ;  tying  in  labour,  307  ; 
vein  of,  112 


Galactocelb,  1111 

Galactorrhoea,  1104 

Ganglion  cervicale  uteri,  209  ;  diseased, 
as  cause  of  post-partum  haemorrhage, 
982^ 

Gangrene,  as  result  of  embolism,  1057 

Gastrotomy,  903.    (&e  Ctesarean  section.) 

Germinal  spot,  42  . 
—       vesicle,  42 

Germs  in  puerperal  fevers,  993 

Gestation.     (^See  Pregnancy.) 

Ginjlvitis,  460 

Glands,  mammary  (see  Breasts)  ;  thyroid, 
changes  of,  in  pregnancy,  557 

Glycerine,  injection  of,  in  induction  of 
premature  labour,  801 

Glycosuria,  in  pregnancy,  556  ;  in  puer- 
peral state,  383 

Gonococci,  in  puerperal  fevers,  994 

Graafian  follicle,  39  ;  maturation  of,  52 


HEMATOCELE,  peritubal,  429  ;  paratubal, 
429 

Hsematoma,  pelvic,  428  ;  of  labium,  660  ; 
of  sternomastoid,  1085  ;  of  the  broad 
ligament,  959 

Hsematometra.  diagnosis  of,  from  preg- 
nancy, 191 

Hsemoptysis,  in  pregnancy,  557 

Haemorrhoids,  in  pregnancy,  492 

Hemorrhage,  accidental  {see  Accidental 
hemorrhage),  608;  concealed,  609;  post- 
partum (.yee  Post-partum  hsemorrhage), 
973  ;  secondary  puerperal,  990  ;  un- 
avoidable (.vee  Placenta  prsevia),  591 

Hand,  choice  of,  in  version,  867,  873  ; 
diagnosis  of,  from  foot,  667 

Head,  foetal,  127.     (_See  Foetal  head.) 

Heart,  diseases  of,  in  pregnancy,  551  ; 
hypertrophy  of,  in  pregnancy,  166 

Heart-sounds,  ffjetal,  185.  {See  Foetal 
heart.) 

Ilegar's  dilators,  581 

—      sign  of  pregnancy,  1 77 

Hemiplegia,  puerperal,  1057,  1061 

Hernia  of  gravid  uterus,  509 

Ileterogenetic  seiiticiemia,  !)97 

Hook,  blunt,  813  ;  small  blunt,  for  use  in 
version,  881  ;  decapitating,  674 


Horrocks'  maieutic,  798 

Hospitals,  lying-in,  prophylaxis  of  puer- 
peral septicaemia  in,  1032 

Hour-glass  contraction  of  uterus,  976 

Hydatid  tumours,  obstructing  labour,  658 

Hydatidiform  mole,  523  ;  treatment  of, 
530 

Hydramnios,  531  ;  treatment  of,  534 

Hydrocephalus,  congenital,  689  (see  142)  ; 
treatment  of,  691 

Hydrops  amnii,  531  ;  treatment,  534 

Hydrorrhoea  gravidarum,  511 

Hydrothorax,  foetal,  obstructing  labour, 
692 

Hygiene  of  pregnancy,  201 

Hymen,  imperforate,  646  ;  in  diagnosis  of 
parity,  193 

Hypoblast,  81 

Hysterectomy  {see  Cesarean  section), 
supra-vaginal,  919  ;  in  hernia  of  uterus, 
509  ;  abdominal,  iu  puerperal  septice- 
mia, 1046 


Icterus,  in  pregnancy,  554  ;  neonatorum, 

307,  400,  1098 
Ilium,  2 

Impregnation,  period  of  possible,  63 
Incarceration  of  retroflexed  gravid  uterus, 

497 
Incision    of    cervix    in   cancer,   652 ;    of 

perineum,  648  ;  of  vagina,  647 
Induction  of  abortion,  803  ;  in  contracted 
pelvis,  759 
—         of  premature  labour,  792  ;    in 
contracted  pelves,  755 
Inertia  of  uterus  in  labour,  623  ;;■  after 

delivery,  981 
Inevitable  laceration  in  primipare,  304 
Infant,  new^-born,  399  ;  artificial  feeding 
of,  410  :  apparent  death  of,  1085  ;  care 
of,  408  ;  care  of,  when  premature,  803  ; 
treatment  of  apparent  death  of,  1089  ; 
suckling  of,  406 
Infarcts  of  placenta,  515 
Infecti.on  in  puerperal  fevers,  1005 
Injections,  intra-uterine,  in  abortion,  587, 
588  ;  as   a   cause   of   sudden 
death,  1058  ;  for  induction  of 
labour,  800  ;  in  post-partum 
hemorrhage,    985  ;    in   puer- 
peral septicemia,  1036 
—      vaginal,  for  induction  of  labour,^ 
799  ;  in  the  puerperal  state, 
402,    1033  ;     in    rigidity    of 
cervix,  637 
Insanitary  conditions,  a   cause   of   puer- 
peral septicemia,  1004 
Insanity  in  pregnancy,  1072;  in  labour, 
1073  ;  in  the  pueiperal  state,  1073  ;  in 
lactation,  1077  ;  treatment  of,  1077 
Insomnia,  in  puerperal  insanity,  1075 
Instrumental  dilators,  (!41 
Insiifilation,    in     asphyxia    neonatorum, 
1093 


iii8 


Index. 


Internal  rotation  in  normal  labour,  251  ; 

in   face   presentation,   329 ;    in   ijelvic 

presentation,  354 
Intoxication,  septic,  996,  1019 
Intra-] igamentous  foetation,  430 
Inversion  of  uterus,  965  ;  treatment,  969 
Involution  of  uterus,  383 
Iodoform  rods,  1034 
Irrigation,  1005.     {See  Injections.) 
ischiopubiotomy,  777 
Ischium,  2  ;  planes  of,  IS 


Jaundice,  in  pregnancy,  554  ;  in  new- 
born child,  307,  400 

Javr  traction  in  contracted  pelves,  750  ; 
in  pelvic  presentation,  363 

Joints.     i^See  Articulations.) 


KiBBiE's  fever-cot  in  puerperal  septi- 
caemia, 1042 

Kidneys,  disease  of,  in  pregnancy,  469 

Knee,  presentation  of,  346  ;  diagnosis  of, 
from  elbow,  667 

Knots  in  funis,  536 

Kyesteine,  169 

Kyphotic  pelvis,  779 


Laborde's  method  of  artificial  respira- 
tion, 1093 

Labour,  203  ;  accidents  during  and  after, 
934;  antesthesia  in,  314  ;  arrest  of,  619  ; 
antiseptic  precautions,  291  ;  causes  of, 
203  ;  collapse  after,  1060  ;  duration  of, 

.  289  ;  induction  of  premature,  755, 
792  ;  mauHgement  of  natural,  290  ; 
mechanism  of,  230  ;  missed,  549  ;  pains 
{see  Pains),  209  ;  position  of  patient  in, 
294  ;  precipitate,  617  ;  prolonged,  619  ; 
stages  of,  216,  226,  281  ;  treatment  of 
protracted,  626 

Laceration,  of  cervix  uteri,  934,  948  ; 
of  genital  canal,  934  ;  of  perineum, 
951  ;  of  uterus,  934  ;  of  vagina,  950  ; 
of  vulva,  951 

Lactation,  diet  of  women  during,  408  ; 
disorders  of,  1103;  insanity  of,  1077; 
management  of,  406 

Laminaria  tents,  in  abortion,  581 

Langhans'  layer,  101,  1063 

Lateral  obliquity  of  foetal  head,  262.  {See 
Obliquity.) 

Lead  poisoning  as  cause  of  abortion,  571 

Leiter's  temperature  regulator,  1041 

Leucocytes  in  puerperal  fevers,  1007 

Lever  {nee  Vectis)  ;  action  of  forceps  as,  853 

Levret's  forceps,  824 

Ligature  of  funis,  306 

Liquor  amnii,  87  ;  deficiency  of,  536  ; 
function  of,  in  labour,  88,  219 

Litliopasdion,  440 

Liver,  acute  atrophy  of,  in  pregnancy, 
554  ;  functions  of,  in  foetus,  125 


Lochia,  391  ;  arrest  of,  1016  ;  decomposi- 
tion of,  1016 

Locking,  of  forceps,  844  ;  of  twins,  681 

Longings,  unnatural,  in  pregnancy,  169, 
1072 

Lower  uterine  segment,  155 

Lungs,  diseases  of,  in  pregnancy,  553  ;  in 
puerperal  state,  1013 

Lying-in  hospitals,  prophylaxis  of  puer- 
peral septiccemia  in,  1032 

Lymphangitis,  1008 

Lymphatics  of  uterus,  in  pregnancy,  150  ; 
in  puerperal  septictemia,  1010 


Maceration  of  foetus,  545 

Maieutic,  Horrocks',  798 

Malacosteon  pelvis,  763 

Malarial  fever,  in  pregnancy,  561 

Malformations  of  uterus  and  vagina,  493 

Malposition  of  os  iiteri,  645 

Mamma.     {See  Breast.) 

Mammary  abscess,  1107  ;    treatment   of, 
1109 
—         changes  in  pregnancy,  ]  65 

Mania,  1070.     {See  Insanity.) 

Marginal  insertion  of  funis,  512 

Mastitis,  parenchymatous,  1107 

Measles  in  pregnancy,  564 

Mechanism  of  labour,  230  ;  in  foot  or 
knee  presentation,  357;  in  pelvic  pre- 
sentation, 352 ;  in  face  presentation, 
328  ;  in  the  flattened  pelvis,  725  ;  in 
the  oblique  pelvis,  776  ;  in  dorso-pos- 
terior  positions  of  tlie  breech,  355  ;  in 
occipito-posterior  positions,  256 

Meconium,  118 

Melancholia,  1070.     {See  Insanity.) 

Membrana  granulosa,  40 

Membranes,  anomalies  of,  694  ;  examina- 
tion of,  311  ;  functions  of,  in  labour, 
216  ;  rupture  of  {see  Kupture  of  mem- 
branes), 219 

Meningocele,  693 

Menstruation,    43  ;  theory   of,   48  ;   com- 
mencement and  duration  of,  60  ;  cessa- 
tion of,  in  pregnancy,  171 ;  continuance 
-  of,  in  pregnancy,  590 

Mento-posterior  positions  (unreduced), 
330  ;  management  of,  342 

Mesoblast,  80  ;  cleavage  of,  81 

Mesoderm,  formation  of,  80 

Metritis,  in  puerperal  fevers,  1007 

Micrococci,  in  puerperal  fevers,  993;  in 
septic  thrombi  and  emboli,  1012 

Mikulicz'  tampon,  452 

Milk,  394  ;  artificial  human,  413  ;  ass's, 
410;  composition  of,  335;  cow's,  410  ;  de- 
fective secretion  of,  406, 1103  ;  excessive 
secretion  of,  1104  ;  goat's,  410;  means 
of  arresting  secretion  of,  408,  1109  ; 
modified,  414  ;  secretion  of,  394 

Milk  fever,  394 

—  laboratories,  414 

—  leg,  1048 


Index. 


1 1 19 


Miscarriage,  493.     {See  Abortion.) 
Missed  abortion,  521 

—      labour,  .549 
Mole,  carneoiis  or  fleshy,  519 ;  tubal,  425  ; 

vesicular,  523 
Monster,  acardiac,  537  ;  acardiac  acepha- 

lie,   369  ;    anencephalic,    686  ;    double, 

632 
Morning  sickness  in  pregnancy,  172 
Mortality  of  childbirth,  319,  1033 
Moulding  of  foetal   head  in  vertex   pre- 
sentation,  268  ;  in   face   presentation, 

336  ;  in  brow  presentation,  340 
Movements,   foetal,    183:  of   foetal  head. 

214 
Miiller,  ring  of,  156 
Multiple    pregnancies,    365  ;     causation, 

365  ;  diagnosis   of,    372  ;    management 

of  labour  in, 374 
Mummification  of  foetus,  547 
Muscles,  action  of  abdominal,  in  labour, 

235 
Muscular  action,  effects  of,  on  pelvis,  30 
Myoma,  559.     ((Sfefl  Fibroid  tumours.) 


Naegele,  lateral  obliquity  of,  262,  333, 
728  ;  oblique  pelvis  of,  771 

Narcotics,  in  eclampsia,  487  ;  in  labour, 
315  ;  in  post-partum  haemorrhage,  988  ; 
in  phlegmasia  dolens,  1052  ;  in  puer- 
peral insanity,  1078  ;  in  threatened 
abortion,  579 

Nausea  in  pregnancy,  455 

Nephritis  in  pregnancy,  470 

Nerves  of  uterus,  150 

Nervous  shock  after  delivery,  1059 

—      system     in     the     foetus,     125  ; 
changes  in  pregnancy,  169 

Neuralgia  in  pregnancy,  461 

New-born  child,  399.    [See  Infant.) 

Nipples,  changes  of,  in  pregnancy,  165  ; 
depressed,  1105  ;  excoriations  and  fis- 
sures of,  1105 

Noose,  use  of,  in  version,  to  prolapsed 
arm,  878  ;  to  leg,  881 

Nulliparous  uterus,  characters  of,  397 

Nurse,  wet,  selection  of,  409 

Nursing,  406.     (<Si?e  Lactation.) 

Nutrition  of  foetus,  125 


Oblique  pelvis  of  Naegele,  771 ;  scoliotic, 
769  :  due  to  disease  of  one  leg,  770 

Obliquity,  lateral,  of  foetal  head,  262  ;  in 
flattened  pelvis,  727  : 

Obstetrical  paralysis,  1084 

Occipito-anterior  positions,  240  ;  mechan- 
ism in,  245 

Occipito-posterior  positions,  240  ;  manage- 
ment of,  301  ;  mechanism  in,  256  ;  use 
of  vectis  in,  821 

Uidenia,  in  albuminuria  of  pregnancy,  469  ; 
of  placenta,  532  ;  in  pregnancy, 491  ;  of 
foetus,  688 


Oldham's  perforator,  884 

Oocytes,  fertilisation  of,  67  ;  formation  of, 
3.5  ;  maturation  of,  65 

Operations,  surgical,  in  pregnancy,  560 

Ophthalmia  neonatorum,  1095 

Opiates.     (See  Narcotics.) 

Osteo-malacia,  763 

Osteophytes,  puerperal,  168 

Os  uteri  {nee  Cervix  uteri)  ;  atresia  of, 
646  ;  dilatation  of,  in  labour,  217,  223  ; 
position  of  internal,  in  pregnancy 
and  labour,  157  ;  malposition  of,  645  ; 
rigidity  of,  635 

Ovarian  foetation,  420 

— •  tumours,  in  pregnancy,  558  ;  diag- 
nosis of,  from  pregnancy,  191  ; 
in  labour,  657 

Ovaries,  anatomy  of,  39  ;  development  of, 
34 

Ovaritis,  1012 

Ovulation,  34,  53 
Ovules,  development  of,  34 
Ovum,  early  development  of,  65  ;  changes 
in,  79;  diseases  of,  510  ;  early  human, 
71  ;  fecundation  of,  63  ;  premature  ex- 
pulsion of,  566  ;  primordial,  35  ;  seg- 
mentation of,  67 

Ovum  forceps  in  abortion,  585 

Oxytocics,  for  induction  of  labour,  571 
{nee  800)  ;  in  protracted  labour,  629 


Pain,  cause  of,  in  labour,  162 

Pains,  labour,  209  ;  anomalies  of,  624  ; 
duration  of,  289  ;  effect  of,  on  foetal  and 
maternal  heart,  214  ;  irregular,  624  ; 
nervous  mechanism  of,  206  ;  premoni- 
tory, 215 ;  spasmodic,  624  ;  spurious, 
215 

Palpation,  abdominal,  in  pregnancy,  173, 
273,  295 

Palpitation  of  heart  in  pregnancy,  462 

Panhysterectomy,  651,  920,  946 

Paralysis  from  cerebral  hsemorrhage,  1061 ; 

-  from  embolism  of  cerebral  arteries,  1057  ; 
in  new-born  infant,  1084 

Parametritis  (.see  Pelvic  cellulitis),  1008  ; 
remote,  1010 

Parity,  diagnosis  of,  396 

Parous  uterus,  characters  of,  398 

Parturient  canal,  axes  of,  20,  22 

Parturition,  203.     {See  Labour). 

Pelvic  cellulitis,  1008;  symptoms  and 
course,  1021  ;  treatment,  1042 

—  peritonitis,    1010 ;    symptoms   and 

course,  1021  ;  treatment,  1042 

—  presentations,  345  ;  causes  of,  347  ; 

blunt  hook  in,  813 ;  bringing 
down  leg  in,  809  ;  extraction  of 
head  in,  361 ;  extraction  of  foetus 
in,  806;  diagnosis,  348;  digital 
traction  in,  811  ;  embryotomy 
in,  902  ;  extraction  of  trunk  in, 
80H  ;     forceps    to     after-corning 


II20 


Index. 


head  in,  859  ;  forceps  to  breech 
in,  814  ;  heart-sounds  in,  188  ; 
impaction  in,  806  ;  injuries 
to  foetus  in,  819  ;  liberation 
of  arms  in,  815  ;  management 
of,  359  ;  mechanism  of,  352 ; 
prognosis,  358 ;  soft  fillet  in, 
811  ;  varieties  of,  347 

Pelvimeter,  701 

Pelvimetry,  701  ;  external,  701  ;  internal, 
704 

Pelvis,  asquabiliter  justo  major,  697  ; 
sequabiliter  justo  minor,  711  ;  anatomy 
of,  1;  articulations  of,  10  ;  axes  of,  20, 
22  ;  bedridden,  785  ;  brim  or  inlet,  4  ; 
changes  in,  from  double  congenital  dis- 
location of  hips,  734  ;  chondo-dystro- 
phic,  724  ;  contracted,  697,  710  ;  de- 
velopment, 25  ;  diameters  of,  16  ;  dif- 
ference between  male  and  female,  5  ; 
dwarf,  715  ;  enlarged,  697  ;  flattened, 
715  ;  generally  contracted,  711  ;  high 
assimilation,  784  ;  inclination  of,  8  ; 
infantile,  23,  711  ;  kyphotic.  779  ;  mala- 
costeon,  763  ;  masculine,  714  ;  male,  5  ; 
measurements  of,  15 ;  osteomalacic,  763  ; 
oblique,  of  Naegele,  771  ;  oblique,  scoli- 
otic, 769  ;  obhque  from  disease  of  one 
leg,  770  ;  outlet  of,  5  ;  planes  of,  22  ; 
pseudo-malacosteon,  766  ;  rachitic,  714, 
717,  766  ;  Kobert's,  777  ;  scoliotic,  769  ; 
split,  735 ;  spondylolisthetic,  785  ; 
straits  of,  5  ;  transversely  contracted, 
777  ;  tumours  of,  obstructing  labour, 
658,  694  ;  triradiate,  763,  769 

Perforation,  883.     (See  Craniotomy.) 

Perforator,  Oldham's,  884  ;  Simpson's,  884 

Pericarditis  in  puerperal  septictemia,  1013 

Perimetritis,  1010.  QSee  Pelvic  perito- 
nitis.) 

Perineum,  distension  of,  in   labour,  227 
examination    of,   after    delivery,   312 
laceration  of,  951  ;  preservation  of,  302 
rigidity  of,  647  ;  treatment  of  lacerated, 
954 

Peritonitis,  pelvic,  1010.     (5ee  Pelvic  peri- 
tonitis.) 
—    in  puerperal  septicgemia,  1010, 1021; 
in  abortion,  537  ;  in  extra-uterine 
foetation,  428 

Pessary,  in  retroflexion  of  gravid  uterus, 
504  ;  in  prolapse  of  gravid  uterus,  508 

Peters'  ovum,  72 

Phlebitis,  in  puerperal  septicemia,  1012, 
1020 

Phlegmasia  dolens,  1048 ;  treatment,  1052 

Phthisis,  in  pregnancy,  553  ;  in  puerperal 
insanity,  1076 

Physometra,  964 

Pigmentation  in  pregnancy,  170 

Placenta,  adhesion  of,  974  ;  anatomy  of, 
96;  anomalies  of,  512  ;  artificial  separa- 
tion of,  978  ;  battledore,  512;  calcifica- 
tion of.  516  ;  circulation  in,  103  ;  cotyle- 
dons of,  104  ;     decomposition  of,  998  ; 


diseases  of,  512  ;  detachment  of,  281  ; 
development  of,  99 — 103  ;  examination 
of,  311  ;    expulsion  of,  285  ;  expression 
of,  309 ;  functions  of,  107  ;  infarcts  of, 
515;  inflammation   of,  514;   in   extra- 
uterine foetation,  452  ;  in  multiple  preg- 
nancy, 367,  368  ;  mechanism  of  detach- 
ment, 281  ;  CEdema  of,    518  ;  retention 
of,  973  ;  retention  of,  in  abortion,  585 
separation  of,  287  ;  thrombosis  of,  518 
tubercle    of,    517  ;     tumours    of,    517 
varieties  of,  in  animals,  96  ;  viUi  of,  96 
Placenta  membranacea,  513 

—  prfevia,  590  ;  cause  of  bleeding  in, 

598  ;  cervix  uteri  in,  596  ;  patho- 
logical anatomy,  597  ;  symptoms 
and  course,  600  ;  treatment,  603 

—  succenturiata,  513 

—  velamentosa,  512 
Placentitis,  514 

Planes  of  ischium,  18  ;  of  pelvis,  21,  22 

Pleurisy,  1013 

Pleuroperitoneal  space,  82 

Plugging  vagina  in  abortion,  580;  in 
accidental  hfemorrhage,  614  ;  in  pla- 
centa prsevia,  604 

Plural  pregnancy,  365.  (^See  Multiple  preg- 
nancies.) 

Pneumococcus  in  fatal  septicaemia,  994 

Pneumonia  in  pregnancy,  554  ;  relation 
to  puerperal  fever,  1002  (see  994)  ;  as 
complication  of  puerperal  septiccemia, 
1013 

Podalic  version,  865 

I'olarity  of  uterus,  212 

Polypus,  obstructing  labour,  654 

Porro's  operation,  916 

Porte-fillet,  812 

Positions  of  foetus  in  vertex  presentation, 
239  ;  diagnosis  of,  273 

Position  of  patient  in  labour,  294 

Post-partum  hsemorrhage,  979  ;  causation, 
981  ;  plugging  uterus  in,  986  ;  pro- 
phylaxis, 983  ;  treatment,  985 

Precipitate  labour,  617 

Pregnancy,  abnormalities  of  uterus  in, 
493  ;  accidental  complications  of,  551  ; 
changes  in  the  maternal  organism  in, 
145;  diagnosis  of,  171,  190  ;  Hegar's 
sign,  177  ;  diet  in,  201  ;  disorders  of, 
due  to  reflex,  toxic,  and  mechanical 
causes,  455  ;  diseases  of  decidua  and 
ovum  in,  510  ;  duration  of,  195  ;  extra- 
uterine, 417  ;  haemorrhage  in,'  452  ; 
hygiene  of,  201  ;  in  rudimentary  uterine 
horn,  436  ;  management  of,  201  ; 
mechanical  effects  of,  162  ;  multiple, 
365  ;  surgical  operations  in,  560 

Pregnancy,  abnormal,  417  ;  causation,  417  ; 
diagnosis,  442  ;  hsematocele  and  hsema- 
toma  in,  428  ;  mortality  in  cases,  445  ; 
pathological  anatomy,  420  ;  prognosis, 
445  ;  symptoms,  440  ;  treatment,  446  ; 
varieties  of,  417 

Premature  expulsion  of  ovum,  566 


Index. 


I  121 


Premature  labour,  induction  of,  755,  792 
Presentation,    136  ;    arm,    6(56  ;    breech, 
345  ;    brow,  322,  339  ;   cause  of  head, 
140  ;  compound,  677,  678  ;  face,   321  ; 
foot,  346 ;  funis,  959  ;  knee,  346  ;  pelvic, 
345  ;   shoulder,   345  ;  transverse,   663  ; 
vertex,  239 
Pressure,  external,  use  of,  in  protracted 
labour,  627  ;  in  pelvic  presenta- 
tions, 361,  810 

—  general  intra-uterine,  231  ;    direct 

uterine,  232 
Primiparity,  diagnosis  of,  193 
Primitive  trace,  85 

—  ova,  34 

Prochownick's  method  of  artificial  respira- 
tion, 1093 
Prolapse  of  funis,  959  ;  treatment,  961 

—  of  uterus  and  vagina  in  pregnancy, 

505  ;  treatment,  508 
Promontory,  false,  732 
Protracted  labour,  619  ;  general  efEectsof, 
619  ;  treatment  of,  in  first  stage,  626  ; 
treatment,  in  second  stage,  627 
Pruritus  in  pregnancy,  462 
Pseudocyesis,  165,  191 
Pseudo-malacosteon  pelvis.  76(5 
Ptyalism  in  pregnancy,  460 
Pubiotomy,  753,  931 

Puerperal  eclampsia,  474  ;  causation,  477  ; 
diagnosis  of,  485 ;  pathological 
anatomy,  480  :  treatment,  486 

—  fevers,   992  ;    causation    of,    997  ; 

death  rates  from,  1000,  1025  (nee 
1026)  ;  diagnosis  of,  1026  ;  infec- 
tion in,  1005  ;  mortality  of,  1000  ; 
organisms  in,  993 — 996  ;  patho- 
logical anatomy  of,  1006  ;  prophy- 
laxis, 1028  ;  symptoms  of,  1015  ; 
treatment,  1034  ;  varieties,  996 

—  osteophytes,  108 

—  septicaemia,  organisms  present  in, 

994 

—  state,  body  weight  in,  393  ;  condi- 

tion of  blood  in,  392  ;  diagnosis 
of,  395  ;  diet  in,  403  ;  manage- 
ment of,  401  ;  secretions  and 
excretions  in,  382  ;  physiology 
of,  380  ;  temperature  in,  380  ; 
treatment  of,  403 

—  ulcers,  1019 

Pulmonary  arteries,  embolism  and  throm- 
bosis of,  1052 

Puncture  of  membranes,  for  induction  of 
abortion,  805  ;  for  induction  of  prema- 
ture labour,  793  ;  in  accidental  haemor- 
rhage, 613  ;  in  placenta  prajvia,  605 

Pyaemia  in  puerperal  state,   1013,  1021 
in  puerperal  insanity,  1076 

Pyelonephritis  of  ttregnancy,  557 

Pyrosis  in  pregnancy,  460 


Quickening,  183 
M. 


Race,  influence  of,  on  fietal  skull,  133  ; 

on  pelvis,  7 
Rachitic  pelvis,  flattened,  715  ;  generally 

contracted,    711  ;    pseudo-malacosteon, 

766  ;  scoliotic,  769 
Rachitis,  intra-uterine.  543 
Rectocele,  659 
Recto-vaginal  fistula,  739 
Refrigeration  in  puerperal  fevers,  1041 
Relapsing  fever  in  ])regnancy,  564 
Reposition  of  funis,  962 
Repositor,  funis,  Roberton's,  964  ;  catheter 
adapted  as,  964 

— ■    Aveling's,  for  inversion   of   uterus, 
971 
Resistance  of  labom-,  238 
Respiration,  artificial,  in  asphyxia  neona- 
torum, 1090  ;  changes  of,  in  pregnancy, 

167 
Restitution  of  foetal  head,  255  ;  in  face 

presentation,      331  ;       in      unreduced 

occipito-posterior,  259 
Retention  of  placenta,  in  abortion,  586  ; 
after  delivery,  973 

—  in  utero  of  blighted  ovum,  521, 545  ; 

of  dead  foetus,  545 

—  of  urine,  in  labour,  659;  in  puer- 

peral state,  211.  404 
Retraction  of  uterus,  621 

—  ring,  156,  621 

Retroflexion   and  retroversion  of   gravid 

uterus,   496  ;    results,  498  ;   symptoms, 

500  ;  treatment,  502 
Rheumatic  fever  death  rates  from,  1000. 

1025 
Rickets   {see   Rachitic   pelvis),    operation 

of,  in  causing  pelvic  deformity,  719 
Rigidity  of  cervix  uteri,  spasmodic,  634  ; 
organic,  635  ;  treatment,  637 

—  of  perineum,  647 
Ring  of  Bandl,  156,  621 

Robert's   transversely   contracted   pelvis, 

777 
Roper's  craniotomy  forceps,  889 
Rotation,    external,    of    foetal    head,   in 

vertex  presentation,  255  ;  in  face 

presentation,  332 

—  internal,   in   vertex    presentation, 

251  ;  in  pelvic  presentation,  352  ; 
in  face  presentation,  329 

Rotations  of  foetal  head,  in  passing  flat- 
tened pelvis,  725 

Rupture  of  membranes,  artificial,  in 
labour,  300  ;  for  induction  of 
labour,  793  ;  in  accidental 
haemorrhage,  613  ;  in  placenta 
praevia,  605 

—  of  membranes,  spontaneous,  219, 236 

—  of   genital   canal,  934  ;    of   pelvic 

articulations,  958  ;  incomplete, 
of  uterus,  946 

—  of   perineum,    951  ;    central,   953  ; 

treatment,  954 

—  of  sac  i  n  extra-uterine  f cetation,  427 

—  of  spleen  in  labour,  1060 

71 


I  122 


Index. 


Rupture  of  uterus  and  vagina,  934  ;  treat- 
ment, 942 
Eut,  analogy  of,  to  menstruation,  49 


Sacro-ILIAC  articulation,  10  ;  action  of. 
as  f ulci'um  of  lever.  29  ;  movement  at, 
in  labour,  10 

Sacrum,  2  ;  changes  in.  25  ;  mechanical 
action  of,  13 

Salivation  in  pregnane}',  460 

Salpingitis,  1012 

Saprajmia  in  pueri)eral  state,  996,  1019 

Sanger's  operation.  904 

Saprophytic  organisms  in  puerperal 
fevers,  995 

Scarlatina,  in  pregnancy,  .564  ;  in  puer- 
peral state,  10(11  ;  relation  of,  to  i>uer- 
peral  fevers,  1001  ;  death  rates  from, 
1000,  102.5 

Scalp-tumour,  22;'..  (See  Caput  suc- 
cedaneum.) 

Schultze's  method  of  artificial  respira- 
tion, 1092 

Scoliotic  pelvis,  769 

Scopolamine  morphine  narcosis,  318 

Secondary  areola,  16") 

Section,  Cassarean,  9ii3.  (See  Ci«sarean 
section.) 

Secretion  of  milk,  394 

Secretions,  in  pregnancy,  168  ;  in  puer- 
peral state,  382 

Segmentation  of  ovum,  67 

Sei)tic;€mia,  after  abortion,  r)77  ;  in 
puerperal  state,  996,  1013,  1019.  (_See 
also  Puerperal  fevers.) 

Septicemic  endometritis,  840 

Septic  infection  ami  sci)tic  intoxication, 
992,  1019 

Serous  lochia.  391 

Sex,  influence  of,  on  the  foetal  skull.  133  ; 
prediction  of,  189 

Shield,  nipple,  1106 

Shock,  after  delivery,  10.59 

Shortening,  ap[)arent,  of  cervix  in  preg- 
nancy, 159 

Shoulder  presentations,  663  :  diagnosis, 
666  ;  varieties,  665  ;  natural  termina- 
tions, 668  ;  ti'eatment,  673 

Shoulder,  delivery  of,  in  head  presenta- 
tion, 305  ;  in  pelvic  presentation,  361. 
819 

"Show,"  in  labour.  217 

Sickness,  455.     (Scr  Yomiting.) 

Signs  of  pregnancy.  170  ;  recapitulation 
of  signs,  190 

Silvester's  method  of  artificial  respira- 
tion, 1090 

Simpson's  basilyst,  897  ;  forceps,  831  ; 
perforator.  8S4 

Sinuses  of  uteru*,  149;  in  puerperal 
state,  389 

Sitting,  effect  of,  on  pelvis,  30,  699 

Skin,  pigmentation  of,  in  pregnancy,  170 

Sleeplessness.  1075.     {See  Insomnia.) 


Small-pox,  in  pregnancy,  563 

Smellie's  forceps,  825 

Somatopleure,  82 

Souffle,  funic,  189  ;  uterine,  184 

Spasmodic  rigidity  of  cervix,  634 

Spermatozoa,  61 

Spina  bifida  obstructing  labour,  694 

Spinal  an£esthesia,  316 

—  cord,  function  of,  in  labour,  207 
Spines  of  iliac,  distance  between,  702 

—  of  ischia,  18 
Splanchnopleure,  82 

Spleen,  rupture  of,  in  labour,  1060 
Spondylolisthetic  pelvis,  785 
Spondylotomy,  677 
Spontaneous  evolution,  670  ;  arrested,  671 

—  rectification,  668 

—  version,  669 
Spot,  germinal,  42 
Spurious  pains,  215 

—  pregnancy,  191 

Stages  of  labour,  216  ;  first,  216  ;,  relative 
effects   of   protracted   labour   in,    626  ; 
second,  or  expulsive,  216  ;  third,  226 
Staphylococci  in  fatal  cases  of  puerperal 

septicaemia,  994 
Stenosis  of  os  uteri,  500  ;  of  vagina,  501 
Streptococci  in  puerperal  fevers,  994,  998^ 

1007 
Suckling,  306.     (See  Lactation.) 
Sudden  death  during  or  after  labour,  1048 
Sugar    in    urine,    556.     (See    Gl^'cosuria 

and  Diabetes.) 
Super-fecundation,  366 
Super-fcetation,  376 
Supra-vaginal  hysterectomy,  919 
Surgical  operations  in  pregnancy,  560 
Suspended       animation,       1085.         (See- 

Asphyxia  neonatorum.) 
Sutures  of  foetal  head,  128 
Symphysiotomy,  753,  923  ;  secondary,  90O 
Symphysis  pubis,  relaxation  of,  in  preg- 
nancy, 12  ;  rupture  of,  958 
Syphilis,    in   pregnancy,    561  ;    affecting 
foetus,    541  ;   as   a   cause   of  abortion, 
570  ;  of  placenta,  516 

Tarnier's  axis-traction  forceps,  828,  856- 
Tetanirs,  in  pregnancy,  562  ;   of   uterus^ 

620  ;  in  puerperal  state,  1047 
Tetany,  562 

Thermostatic  nurse,  Hearson's,  803 
Thornton's  ice-water  cap,  1041 
Thrombosis,  of  pulmonary  arteries,  1052 ;. 

of  veins,  1048  ;  in  puerperal  septicagmia,. 

1012  ;  of  placenta,  515,  518 
Thrombus  of  vagina  and  vulva,  660 
Thyroid  gland  in  pregnancy,  557 
Tongue-tied  infant,  1097 
Torsion  of  funis,  538 
lYansfusion  of  saline  fluid,  988 
Transverse  piesentations,  663,  759 
Trephine  perforator,  885 
Triradiate  pelvis,  763,  766 
Trismus  uteri,  634 


Index. 


1 123 


Trunk,  expulsion  of,  304  ;  in  pelvic  pre- 
sentation, 354  ;  extraction  of,  in  pelvic 
presentations,  808 

Tubal  foetation,  423  ;  rupture  of,  426 

Tubal  mole,  425 

Tubercle  of  placenta,  517 

Tubo-ovarian  foetation,  429 

Tubo-uterine  foetation,  429  ;  diagnosis 
from  tubal  foetation,  480 

Tumours,  diagnosis  of,  from  pregnancy, 
171  ;  ovarian,  558,  657 ;  of  pelvis, 
causing  dystocia,  658  ;  of  foetus,  694, 
of  placenta,  517 

Tunica  albuginea,  38  ;  fibrosa,  40  ; 
interna,  40 

Turning,  861.     (^See  Version.) 

Tussenbroeck's  case  of  ovarian  pregnancy, 
420 

Twin  pregnancy,  365.  {See  Multiple  preg- 
nancies.) 

Twins,  binocular,  366  ;  conjoined,  682  ; 
locked,  obstructing  labour,  681  ;  uni- 
ovular, 366 

Tympanites,  in  puerperal  septicaemia,  1018; 
uteri,  964 

Typhus  fever,  in  pregnancy,  564 

Ulcers,  puerperal,  1019 
Umbilical  cord,  112.     {^Sec  Funis.) 

■ —     vesicle,  82 
Unavoidable     hiemorrhage,     590.       (^See 

Placenta  priEvia.) 
Unreduced    positions,    occipito-posterior, 

259  ;  mento-posterior,  330 
Uraemia,  in  eclampsia,  476  ;  in  puerperal 

insanity,  1074 
Urea  in  liquor  amnii,  87 
Ureter,  dilatation  of  foetal,  88,  692 
Urethra,  imperforate,  of  foetus,  88,  692 
Urine  in   pregnancy,   168  ;   retention  of, 
in  labour,  659  ;  in  puerperal  state,  382 
Uterine  souffle,  184 

Uterus,  abnormalities  of,  in  pregnancy, 
493 ;  anterersion  and  anteflexion  of, 
494  ;  arteries  of,  149  ;  atresia  of,  645  ; 
axis  of,  in  labour,  625  ;  changes  in,  in 
pregnancy,  145,  173  ;  continuous  action 
of,  620  ;  contractions  of,  in  pregnancy, 
180;  contractions  of,  in  labour,  206; 
distinctions  between  nulliparous  and 
parous,  397 ;  evacuation  of,  in  abor- 
tion, 583  ;  fundal  incision  of,  in 
Csesarean  section,  908  ;  hernia  of,  509  ; 
hour-glass  contraction  of,  976  ;  inertia 
of,  623  ;  injections  into  [see  Injections), 
587  ;  irregular  contractions  of,  624  ; 
iri-igation  of  (see  Injections),  587  ;  in- 
version of,  965  ;  involution  of,  383  ; 
lymphatics  of,  150  ;  motor  centre  of, 
207  ;  muscular  fibres  of,  147  ;  nerves 
of,   150  ;  perforation  of,  947  ;    polarity 


of,  212  ;  prolapse  of,  505  ;  retraction  of, 
211,  621  ;  retroflexion  and  retroversion 
of,  496  ;  rupture  of,  934  ;  segments  of, 
156;  sinuses  of,  149,  389;  size  of,  in 
successive  months  of  pregnancy,  150  ; 
tumours  of,  559,  653  ;  tetanus  of,  620  ; 
tympanites  of,  964  ;  veins  of,  149 

Vagina,  atresia  of,  646 ;  colour  of,  in 
pregnancy,  180  ;  in  pregnancy,  161,  180, 
390  ;  in  puerperal  state,  390,  396  ; 
irrigation  of  Q<ee  Injections),  402  ; 
laceration  of,  950  ;  mode  of  expansion 
of,  in  labour,  223  ;  mode  of  plugging, 
580,  604,  614  ;  results  of  plugging,  614  ; 
prolapse  of,  505,  659  ;  thrombus  of,  660 

Vaginal  Caesarean  section,  645,  922 

Vaginitis,  1006 

Valve,  Eustachian,  121 

Varicose  veins  in  pregnancy,  491 

Variola,  in  pregnancy,  563 

Vectis,  820  ;  in  occipito-posterior  posi- 
tions, 821 

Veins,  entrance  of  air  into,  1057  ;  in- 
flammation of,  1012 ;  thrombosis  of, 
1021  ;  varicose,  in  pregnancy,  491 

Venesection  in  eclampsia,  488 

Ventral  stalk,  84 

Version,  anfesthesia  in,  866  ;  after  crani- 
otomy, 899  ;  bipolar,  866,  872  ;  cephalic, 
861  ;  choice  of  hand  in,  867,  873  ; 
choice  of  leg  in,  871,  878  ;  combined 
external  and  internal,  864 ;  in  acci- 
dental hfemorrhage,  616  ;  in  cancer  of 
cervix  uteri  and  pelvis,  653  ;  in  flattened 
pelves,  742  ;  in  placenta  prsevia,  606  ; 
in  prolapse  of  funis,  963  ;  in  shoulder 
presentations,  865  ;  internal,  878  ; 
podalic,  865  ;  spontaneous,  669 

■  Vertex  presentations,  cause  of,  138  ; 
positions  of  head  in,  239  ;  movements 
of  foetal  head  in,  244  ;  moulding  of 
head  in,  268  ;  diagnosis  in,  273 

Vesicle,  germinal,  42  ;  umbilical,  82 

Vesico-vaginal  fistula,  738 

Villi,  chorionic,  95 

Vomiting  of  pregnancy,  455  ;  treatment, 
458 

Vulva,  atresia  of,  646  ;  laceration  of,  646  ; 
pruritus  of,  951  ;  in  pregnancy,  462  ; 
thrombus  of,  660 ;  ulcers  of,  in  puer- 
peral septicasmia,  1019 

Walcher's  position,  11,  838 
Weight  of  foetus,  120 
Wet-nurse,  selection  of,  409 

Zona  pellucida,  42 

Zymotic  diseases,  in  pregnancy,  562  ; 
relation  of,  to  puerperal  fevers,  1001 


HRAlJHrKV,    AflNKW,    &    UO.    LD.,    PttlNTKRS,    LONDON    AND   TONHUIDOK. 


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